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TREATISE ON FRACTURES. 



/ BY 

LEWIS A. STIMSON, B.A., M.D., 

1 7 1 

PROFESSOR OF SURGICAL PATHOLOGY IN THE MEDICAL FACULTY OF THE UNIVERSITY 

OF THE CITY OF NEW YORK ; ATTENDING SURGEON TO THE BELLEYUE AND 

PRESBYTERIAN HOSPITALS, NEW YORK ; MEMBER OF THE 

NEW YORK SURGICAL SOCIETY. 



WITH THREE HUNDRED AND SIXTY ILLUSTRATIONS ON WOOD. 





PHILADELPHIA: 
HENRY C. LEA'S SON & CO 

1883. 



$ ° 



Entered according to Act of Congress, in the year 1882, by 

HENRY C.LEA'S SON & CO., 

in the Office of the Librarian of Congress. All rights reserved. 



COLL IX S , PRINTER. 



CONTENTS. 



CHAPTER I. 

GENERALITIES 

Definitions, statistical tables, influence of age, sex, and season 

CHAPTER II. 

VARIETIES OF FRACTURE 

1. Incomplete fractures : 

Fissures ..... 
True, incomplete, or green-stick 
Depressions .... 

Separation of a splinter or apophysis 

2. Complete fractures . 

a. Subdivided according to the direction of the line of fracture 

b. According to the seat of fracture 

Separation of the epiphysis 

c. Intra- articular fractures 

3. Multiple fractures .... 

Comminuted, impacted, with crushing . 

4. Compound fractures .... 

5. Gunshot fractures .... 



CHAPTER III 

DISPLACEMENTS 

Transverse or lateral ; angular ; rotatory ; overriding ; by penetration or crush- 
ing ; direct longitudinal separation. Active causes 



PAGE 

33 
36 



37 

38 
38 
39 
42 
42 
43 
43 
48 
49 
52 
55 
55 
59 
62 



67 



73 



CHAPTER IV. 








ETIOLOGY . . . .76 


. Predisposing causes . . . . . . .76 


Normal or physiological 






76 


Pathological ..... 






76 


Inherited or acquired liability . 






79 


Osteoporosis .... 






80 


Disease of the nerve centres . . 






82 


Rachitis ..... 




/ 


83 


Syphilis, mercurialism, ' ' rheumatism' ' . 






84 



CONTENTS. 



Cancer . . . 

Cysts ; caries and necrosis 

Immediate or determining causes 

a. External violence 

b. Muscular action 
Intra-uterine fractures, and fractures during delivery 



CHAPTER V. 

SYMPTOMS AND DIAGNOSIS 

Objective signs 

Deformity 

Abnormal mobility 

Crepitation 
Subjective or rational signs 

Loss of function ; pain ; history 



CHAPTER VI 



REPAIR OF FRACTURES 



Clinical description 

Anatomo-pathological processes 

History ; nature of the process ; details 

failure of union 
Details in compound fracture 
Details in the short and flat bones 
Details in articular fractures 
Details in fracture of parallel bones 
Details in separation of an epiphysis 



simple fracture ; splinters 



CHAPTER VII. 

COMPLICATIONS AND REMOTE CONSEQUENCES OF FRACTURE 

Stiffness of the joints . 

Atrophy of the limb 

Obliteration of the large veins ; embolism 

Fat embolism . 

Extravasation of blood . 

Injury of an artery ; traumatic 

Emphysema 

Gangrenous septicaemia 

Gangrene 

Suppuration ; pysemia ; necrosis 

Muscular twitchings and tetanus 

Delirium tremens and nervous delirium 

Exuberant and painful callus 

Paralysis due to injury of a nerve 

Paralysis by inclusion of a nerve in the callus 

Secondary fracture 



CONTENTS. 



CHAPTER VIII. 













PAGE 


TREATMENT OF FRACTURES . . .153 


Reduction ....... 




. 154 


Retention .... 










. 159 


Scultetus bandage 










. 160 


Bivalve cushion . 






.- 




. 161 


Wooden splints . 










162 


Fracture boxes . 










. 163 


Gutters .... 










164 


Posterior and suspended splints . 










164 


Malgaigne's point and hooks 










168 


Moulded splints . 










169 


Plaster of Paris . . 










170 


Inclined plane . 










179 


Continuous extension 










179 


Movements, local and general treatment 










184 


Compound fractures .... 










185 


Suture of the fragments 










187 


Antiseptic (Lister) method 










188 


Modifications 










190 


Treatment of inflammatory processes 










192 


Treatment of articular fractures . 










193 


Treatment of gunshot fractures . 










194 


Amputation 










194 


Aphorisms 










195 



CHAPTER IX. 

PSEUDARTHROSIS AND DELAYED UNION 

Causes, general and local 
Softening and absorption of callus 
Diagnosis 

Treatment, internal remedies . 
Local measures . 



197 

201 

207 
208 
209 
210 



CHAPTER X. 

DEFORMED, FAULTY, OR VICIOU 

Treatment 

Infraction of callus 

Rupture of callus 

Division of callus 

Resection of projecting fragment 

CHAPTER XI 

GENERAL PROGNOSIS 

The patient . . . . 

The fracture ..... 



S UNION 



217 

219 
219 
220 
222 
223 



226 

226 
227 



VI 



CONTENTS. 



CHAPTER XII 













PAGE 


FRACTURES OF THE SKULL . . . 230 


Pathological anatomy ...... 


. 232 


Fractures of the vault . 










. 232 


Fractures of the base 










. 234 


Symptoms and diagnosis — vault 










. 239 


Symptoms and diagnosis — base 










. 241 


Prognosis 










. 246 


Treatment — vault 










. 247 


Treatment — base 










. 252 



CHAPTER XIII. 



Pathology .... 


V H.K,X2jL 


itiJth 




. 255 


Etiology .... 








. 260 


Symptoms and diagnosis 








. 261 


Atlas and axis . 








. 263 


Lower cervical and upper dorsal 








. 264 


Lower dorsal and upper lumbar 








. 267 


Lower lumbar . 








. 269 


Course and terminations 








. 270 


Treatment .... 








. 274 



CHAPTER XIV. 

FRACTURES OF THE BONES OF THE FACE 



1. Fractures of the nose 

2. Malar bone and zygoma 

3. Superior maxilla 

4. Inferior maxilla 

Treatment 



CHAPTER XV. 

FRACTURES OF THE HYOID BONE . 



27? 

277 
280 
282 
284 
289 



295 



CHAPTER XVI. 

FRACTURES OF THE CARTILAGES OF THE LARYNX AND TRACHEA 



297 



CHAPTER XVII. 

FRACTURES OF THE STERNUM 



Etiology 
Treatment 



299 

302 
305 



CONTENTS 



Vll 



CHAPTER XVIII 



FRACTURES OF THE RIBS AND THEIR CARTILAGES 



Pathology and complications 
Etiology . . 

Symptoms 
Treatment . 

Fracture of the costal cartilages 



PAGE 

307 

307 
311 
312 
316 
319 



CHAPTER XIX. 

FRACTURES OF THE CLAVICLE 



323 



Pathology . . - . ■ 


. 




. 324 


Middle third 






. 325 


Outer third 


, 




. 327 


Inner third 






. 328 


Multiple fractures 






. 329 


Complications 


. 




. 330 


Etiology .... 






. 332 


Simultaneous fracture of both clavicles 






. 333 


Symptoms and course . 






. 334 


Treatment 






. 337 



CHAPTER XX. 



FRACTURES OF THE SCAPULA 



Of the body of the scapula 

Of the inferior angle . 

Of the upper angle 

Of the spine of the scapula 

Of the acromion 

Of the coronoid process 

Of the surgical neck 

Of the glenoid cavity . 



345 

346 
348 
349 
349 
350 
351 
353 
354 



CHAPTER XXI. 

FRACTURES OF THE HUMERUS 

1. Fractures of the upper end ...... 

Pathology and course ...... 

a. Fractures of the head ..... 

b. Fractures of the anatomical neck, and through the tuberosities 

c. Fracture of the tuberosities .... 

d. Separation of the epiphysis .... 

e. Fracture of the surgical neck .... 

/. Intra- and extra-capsular fractures, -with dislocation of the upp 
fragment ...... 

Diagnosis ....... 

Treatment . . . 



356 

357 
357 
357 
358 
362 
365 
369 

372 
377 
379 



Vlll 



CONTENTS 



2. Fractures of the shaft of the humerus 

Symptoms, treatment 

3. Fractures of the lower end of the humerus . 

1. Fractures above the condyles 

2. Fractures of the epitrochlea 

3. Fractures of the external epicondyle 

4. Fractures of the internal condyle 

5. Fractures of the external condyle 

6. Intercondyloid fractures 

7. Separation of the epiphysis . 

8 Fracture of the articular process 

9. Simultaneous fracture of all three bones 

Diagnosis 

Treatment .... 



PAGE 

384 
386 
389 
390 
391 
395 
396 
403 
405 
411 
413 
413 
414 
415 



CHAPTER XXII. 

FRACTURES OF THE BONES OF THE FOREARM 

A. Fractures in the vicinity of the elbow-joint 

1. Of the olecranon . . . 

Symptoms .... 
Repair .... 

Treatment .... 

2. Of the coronoid process of the ulna . 

3. Of the head and neck of the radius . 

B. Fractures of the shaft 

1 . Of both bones 

Treatment . 

2. Of the shaft of the ulna 

3. Of the shaft of the radius 

C . Fractures in the vicinity of the wrist 

1. Fracture of the radius. Colles's fracture 

Causes .... 

Symptoms and diagnosis 

Course and prognosis 

Treatment .... 

2. Fractures at the wrist other than Colles's 



418 

418 
418 
420 
422 
425 
427 
431 
435 
435 
439 
442 
444 
446 
446 
455 
457 
459 
460 
464 



CHAPTER XXIII. 

FRACTURES OF THE CARPUS AND HAND 



1 . Fractures of the carpus 

2. Fractures of the metacarpal bones . 

3. Fractures of the phalanges . 



466 

466 
467 
469 



CONTENTS 



IX 



CHAPTER XXIV 



FRACTURES OF THE PELVIS 



1. Fractures of the ring of the pelvis . 

Separation of the symphysis pubis 

Separation in front and behind 

Separation of the sacro-iliac synchondrosis 

Separation of all three joints 

Fracture of the pubic portion 

Fracture of the lateral portion 

Course and prognosis 

Diagnosis 

Treatment 

2. Transverse fracture of the sacrum 

3. Fractures of the coccyx 

4. Fractures of the ilium 

5. Fractures of the ischium 

6. Fractures of the pubis 

7. Fractures of the rim of the acetabulum 



PAGE 

472 

472 
473 
475 

475 
475 
476 
477 
480 
480 
481 
481 
482 
483 
484 
485 
486 



CHAPTER XXV. 



FRACTURES OF THE FEMUR 



1. Fractures at the upper end . 

A. Fractures of the neck of the femur . 

Causes 

Anatomical varieties 

a. Fractures of the small part of the neck 

Separation of the epiphysis 

Symptoms 

Repair 

b. Fractures at the base of the neck 

Repair 
Symptoms .... 
Diagnosis .... 
Prognosis . 
Treatment .... 

B. Fracture through great trochanter and neck 

C. Fracture of the great trochanter 

2. Fractures of the shaft of the femur 

Prognosis .... 

Treatment .... 

In children .... 

3. Fractures at the lower end of the femur 

A. Supra-condyloid fracture and separation of epiphysi 

B. Inter-condyloid fracture 

C. Fracture of either condyle . 



488 

4S8 
489 
491 
492 
494 
496 
496 
498 
504 
508 
508 
513 
515 
517 
520 
522 
524 
528 
529 
536 
538 
538 
540 
543 



CONTENTS. 



CHAPTER XXVI 





PAGE 


FRACTURES OF THE PATELLA . 


. 546 


Cause ... . . 


. 546 


Pathology . . . . 


. 547 


Symptoms ....... 


. 550 


Course and terminations ...... 


.550 


Treatment 


. 556 


Of compound and ununited .... 


. 561 



CHAPTER XXVII. 



FRACTURES OF THE BONES OF THE LEO 



A. Fractures of the upper end of both bones, or of the tibia alone 

Treatment . . 

B. Fractures of the shaft 

Treatment 

C. Fractures at the lower end of the leg 

1. Fractures by inversion of the foot 

2. Fractures by eversion of the foot 

D. Fractures of the fibula 

Upper end 

Shaft .... 



564 

564 
567 
567 
570 
576 
578 
581 
586 
586 
587 



CFIAPTER XXVIII. 

FRACTURES OF THE BONES OF THE FOOT 



A. Fractures of the astragalus 

B. Fractures of the calcaneum 

C. Fractures of the metatarsal bones 

D. Fractures of the phalanges . 



588 

588 
589 
592 
593 



LIST OF ILLUSTRATIONS, 



FIG. 

1. Fissured fracture . 

2. Fissure of the humerus 

3. Green-stick fracture of the radius . 

4. 5. Partial fracture of the fibula . 
6, 7. Transverse fracture of the femur 

8. Toothed fracture of the femur 

9. Toothed fracture of the tibia 

10. Y-shaped fracture 

11. Oblique fracture of the humerus . 

12. Oblique fracture of the clavicle . 

13. Oblique fracture of the femur 

14. Longitudinal fracture of the tibia 

1 5. Sepai-ation of the lower epiphysis of the femur 

16. Intra- articular fracture of the head of the tibia 

17. Intra- articular fracture of the humerus 

18. Inter-condyloid fracture of the humerus . 

19. Multiple fracture of the bones of the leg . 

20. Multiple fracture of the fibula 

21. 22. Comminuted fracture of the femur 

23. Comminuted fracture of the radius 

24. Impacted fracture of the neck of the femur 

25. Partial gunshot fracture . 

26. Perforating gunshot fracture 

27. Gunshot fracture .... 

28. Comminuted gunshot fracture 

29. Gunshot fracture with impacted ball 
30,31. Lateral and angular displacement 
32, 33. Angular displacement 

34, 35. Clavicle, union with great displacement 

36. Rotatory displacement 

3 7. Fracture of leg, with overriding . 

38. Fracture of femur, with splitting of the condyles 

39. Fracture of calcaneum, with crushing 

40. Impaction and splitting of the head of the tibia 

41. Impaction of the neck of the femur 

42. Impaction of the neck of the humerus 

43. Angular displacement and impaction of radius 

44. Longitudinal separation, fibula 

45. Patella, bony union 

46. Patella, long fibrous union 



PAGE 

38 
39 
40 
40 
43 
44 
45 
45 
45 
46 
47 
47 
49 
53 
54 
54 
56 
56 
58 
58 
58 
63 
63 
63 
64 
64 
68 
68 
69 
69 
70 
70 
70 
71 
71 
71 
71 
71 
72 
72 



Xll 



LIST OF ILLUSTRATIONS. 



FIG. 

47. Irregular displacement of neck of femur 

48. Irregular disj)lacement of clavicle 

49. Penetration of the astragalus between the tibia and fibula 

50. Comminuted fracture of neck of femur . 

51. 52. Diagram of the bones of the thigh and leg 

53. Clavicle, osteomalacia 

54. United fracture of rachitic femur 

55. Cancer of the femur, fracture 

56. Fracture of carious femur 

57. Diagram concerning measurement of limb 

58. Thermograph in simple fracture 

59. Thermograph in compound fracture 

60. Periosteal bridge 

61. Callus on sixth day, pigeon 

62. Callus on seventh day, rabbit . . , 

63. Callus on fifteenth day . 

64. Callus and adjoining rarefied bone 

65. Large splinter reversed and united 

66. Humerus, failure of union 
6 7, 68. Bony union of patella 

69. Absorption of neck of femur after fracture 

70. Exuberant callus, lower end of humerus 

71. Bony ankylosis of foot and ankle 

72. Forearm, angular displacement and union 

73. Forearm, lateral joint 

74. Fibrous union, olecranon 

75. 76. Necrosis after fracture 

77. Inclusion of a nerve in a callus . 

78, 79. Scultetus bandage 
80, 81. Bivalve cushion 

82. Gooch's flexible wooden splint . 

83. Petit' s fracture box 

84. Scheuer's box splint 

85. Baudens's fracture box . 

86. 87. Wire gutters for arm and leg 

88. Mayor's suspension dressing 

89. Mclntyre's splint and Salter's swing 

90. Suspended fracture box for compound fracture 

91. N. R. Smith's anterior splint 

92. Hodgen's splint . 

93. 94. Hodgen's cradle 
95, 96. Malgaigne's point 

97. Anger's apparatus for alternate pressure 

98, 99. Malgaigne's hooks . 

100. Posterior plaster splint . 

101, 102. Anterior and posterior plaster splint 

103. Bavarian splint . 

104, 105. Plaster of Paris dressing 
106. Fenestrated plaster dressing 



LIST OF ILLUSTRATIONS. 



Xlll 



FIG. 

107. Interrupted plaster dressing . ' . 

108. Esmarch's double inclined plane 

109. 110, 111. Adhesive plaster to make extension 

112. Volkmann's sliding foot-rest 

113. Hamilton's long side splint 

114. Continuous extension by India rubber . 

115. Cripp's splint .... 

116. Campbell de Morgan's splint 

117. Lister dressing, compound fracture 

118. 119. H. H. Smith's splints for ununited fracture 

120. Volkmann's operation for pseudarthrosis 

121. Vicious union, femur 

122. 123. Vicious union, fibula 

124. Vicious union, tibia . 

125, 126. Depressed fracture of skull 

127. Fracture of skull from within 

128. Fracture of the clinoid process . 

129. Fracture of the skull by the condyle of the jaw 

130. Fracture of the base 

131. Fracture of the base, by a blow upon the nose 

132. Fracture parallel to the axis of the temporal bone 

133. Repair after trephining . 

134. Transverse fracture of a vertebra 

135. Compression of the cord by displaced vertebra 

136. Compresion of a vertebra 

137. 138. Fracture and compression of vertebrae 

139. Laceration of spinal cord 

140. Fracture of the axis 

141. Ankylosis by fusion of the vertebrae 

142. Splint for fracture of the upper jaw 

143. Fracture of the lower jaw 

144. 145, 146, 147, 148. Fracture of the lower jaw, dressings 
149, 150. Fracture of the lower jaw, pasteboard splint 

151. Fracture of the lower jaw, metal splint . 

152, 153. Fracture of the lower jaw, Kingsley's splint 

154. Hyoid bone, united fracture 

155. Diastasis of the sternum 

156. Longitudinal fracture of the sternum 

157. Transverse fracture of the sternum 

158. Rib, union after fracture 

159. Rib, exuberant callus 

160. Adhesive plaster dressing for fracture of ribs 

161. 162. Costal cartilage, repair after fracture 

163. Clavicle, oblique fracture 

164, 165. Clavicle, fracture with great displacement 
166, 167. Clavicle, fracture in outer third 

168. Clavicle, fracture in inner third . 

169. Clavicle, union with great displacement . 

170. Clavicle, mechanism of displacement 

171. 172. Clavicle, Mayor's and Velpeau's dressings 



PAGE 

176 
179 
181 
182 
182 
183 
183 
183 
190 
210 
216 
217 
219 
224 
233 
233 
235 
236 
236 
237 
238 
247 
256 
256 
256 
257 
259 
264 
270 
284 
285 
l, 290 
291 
292 
192, 293 
296 
299 
299 
301 
313 
314 
317 
322 
325 
326 
328 
329 
336 
337 
340 



XIV 



LIST OF ILLUSTRATIONS 



FIG. 

173, 174. Clavicle, Sayre's dressing . 

175, 176. Clavicle, Fox's dressing 

177. Clavicle, Reeamier's dressing 

178, 179. Clavicle, Moore's dressing . 

180. Scapula, transverse fracture 

181. Scapula, mnltiple (longitudinal) fracture 

182. Scapula, fracture of posterior angle 

183. Scapula, fracture of coracoid process 

184. Scapula, fracture of the neck 

185. Humerus, fracture of the head . 

186. Humerus, fracture of the anatomical neck 

187. Humerus, fracture of the neck and tuberosities : 

188. Humerus, fracture through the tuberosities 

189. 190. Humerus, impacted fractures at the head . 

191. Humerus, fracture through tuberosities, reversal of head 

192. Humerus, fracture of the greater tuberosity 

193. Humerus, separation of the upper epiphysis 

194. 195, 196. Humerus, upper epiphyseal line 

197. Humerus, separation of upper epiphysis (clinical) 

198. Humerus, separation of upper epiphysis (union) 

199. Humerus, fracture of surgical neck 

200. Humerus, fracture of neck, impaction 

201. Humerus, fracture of neck, displacement 

202. Humerus, fracture of neck, dislocation . 

203. Humerus, moulded splint 

204. Humerus, angular internal splint 

205. Humerus, Middledorpf's triangle 

206. Humerus, fissure .... 

207. 208. Stromeyer's axillary cushion 
209, 210, 211. Humerus, supra-condyloid fracture 

212. Humerus, fracture of epitrochlea 

213. Humerus, fracture of external epicondyle 

214. The elbow-joint ..... 

215. The outward deflection of the forearm . 

216. Relations of the bones of the arm and forearm . 

217. Deformity after fracture at the elbow 

218. Humerus, fracture of the internal condyle 
219-224. Humerus, intercondyloid fracture . 

225. Humerus, intercondyloid fracture, displacement forward 

226, 227. Fracture at elbow, interrupted splints 

228. Humerus, lower epiphyseal line . 

229. Fracture at the elbow, anterior splint 

230. The olecranon, divided vertically 

231. The olecranon, bony union after fracture 

232. The olecranon, fibrous uuion 

233. 234. The olecranon, ununited fracture . 

235. Coronoid process of ulna, union after fracture 

236. Coronoid process of ulna and head of radius, fracture 

237. Neck of the radius, union after fracture 

238. Fracture of the forearm, angular displacement, union 



PAGE 

341 
342 
343 
344 
345 
346 
349 
352 
353 
357 
358 
359 
359 
360 
361 
365 
367 
367 
368 
369 
369 
370 
370 
374 
380 
380 
381 
384 

387, 388 

390, 391 
. 392 
396 
397 
397 
. 398 
399 
401 

405, 406 
410 
411 
412 
416 
418 
422 
423 

424, 425 
429 
429 
433 
439 



LIST OF ILLUSTRATIONS. 



XV 



FIG. PAGE 

239. Fracture of the forearm, formation of lateral joint . . . 439 

240. Fracture of the forearm, Scott's splint ..... 442 

241. Fracture of the shaft of the radius ..... 445 

242. Fracture of radius and ulna ...... 445 

243. 244, 245. Fracture of the lower end of the radius . * . 448 

246. Comminuted fracture of radius, articular surface . . . 449 

247. Recent fracture of the lower end of the radius . . . .449 

248. Impacted fracture of the lower end of the radius . . . 450 
249,250. Fracture of lower end of radius, union .... 450 

251. Fissured fracture of lower end of radius . .... 454 

252. Section through the hand and wrist . . . . . 456 

253. Deformity in Colles's fracture ...... 458 

254. Colles's fracture, union with displacement .... 458 
255,256. Colles's fracture, splints . . . . . 462 

257. Colles's fracture, Levis' s splint . . . . . .462 

258. Colles's fracture, Gordon's splint ..... 463 

259. Gutta percha splint for finger ...... 470 

260. Double vertical fracture of pelvis, united . . . .477 

261. Double vertical fracture of pelvis . . . ."'■•. 478 

262. Perforation of acetabulum by the femur .... 480 

263. Neck of the femur ....... 490 

264. 265. Neck of the femur, impacted intracapsular fracture . 494, 497 
266, 267. Neck of the femur, pure intracapsular fracture, bony union . 500 

268. Neck of the femur, impacted intracapsular fracture . . . 501 

269. Neck of the femur, intracapsular fracture, fibrous union . ■ 501 

270. Neck of the femur, fracture at the base, section . . . . 505 

271. Neck of the femur, impacted fracture without splintering . . 506 

272. Neck of the femur, repair after fracture .... 506 
273-276. Neck of the femur, comminuted fracture . . . 506,507 

277. Neck of the femur, exuberant callus . . . . .507 

278. Bryant's ilio-femoral triangle . . . . . .511 

279. Relaxation of the fascia lata . . . . . . 511 

280. The Y-ligament, in ununited fracture ..... 516 

281. The obturator tendon, in ununited fracture . . . .517 

282. Hennequin's splint for fracture of the neck of the femur . .519 

283. Fracture through the great trochanter ..... 521 

284. Fracture or diastasis of the great trochanter .... 522 

285. 286, 287. Fractures of the shaft of the femur . . . .525 
288, 289. Fractures of upper third of femur, union with great displacement . 526 

290. Fracture of neck and shaft of femur, reversal of a splinter . . 527 

291. Adhesive plaster applied for Ruck's extension .... 529 

292. Volkmann's sliding foot-rest ...... 530 

293. Hamilton's long side splint ...... 531 

294. 295, 296. Long side splints and elastic extension . . . 532 

297. Hennequin's apparatus for fracture of the femur . . . 533 

298. N. R. Smith's anterior splint . . . . . . 534 

299. Hodgen's splint ........ 534 

300. Plaster of Paris dressing, fracture of thigh .... 535 

301. Plaster of Paris dressing, application • . . . . 536 

302. Vertical extension in fracture of femur in children . . . 536 



XVI 



LIST OF ILLUSTRATIONS. 



FIG. 

303. Hamilton's splint for fracture of femur in children 

304. Separation of the lower epiphysis of the femur 

305. 306, 307. Interc'ondyloid fractures of the femur 

308. Plaster splints, suspension 

309. Fracture of the internal condyle of the femur 

310. Patella, incomplete fracture 

311. Patella, vertical fracture 

312. Patella, oblique fracture 

313. Patella, comminuied fracture, bony union 

314. Patella, fibrous union with wide separation 

315. Patella, bony union 

316. Patella, fibrous union 

317. 318, 319. Patella, bony union 

320. Patella, multiple fracture 

321. Patella, extreme separation, clinical 

322. Patella, Agnew's splint . 

323. Patella, Agnew's splint applied . 

324. Patella, Hamilton's dressing 

325. Patella, Laugier's dressing 

326. Patella, treatment by elastic traction 

327. Patella, Malgaigne's hooks 

328. Patella, Levis' s modification 

329. Patella, Trelat's dressing 

330. Patella, LeFort's dressing 

331. Impacted fracture at the upper end of the tibia 

332. Arrest of growth after injury to upper epiphysis of tibia 

333. Y-shaped fracture of the tibia 

334. 335. Fracture boxes 

336. Bonnet's gutter for the leg 

337. Leg encased in plaster of Paris . 

338. Bavarian splint .... 

339. Posterior plaster splint . 

340. 341. Dr. Neill's dressing for fracture of leg 

342. Method of continuous extension in fracture of le 

343. Liston's double inclined plane . 

344, Mclntyre's splint and Salter's cradle 

345, 346. Malgaigne's point . 

347. Anger's apparatus for alternate pressure 

348. Compound fracture, Lister dressing and plaster splint 

349. Anterior and posterior splint 

350. Interrupted plaster dressing 

351. Comminuted fracture of lower portion of leg 

352. Vertical section through the malleoli 

353. Fracture of the internal malleolus 

354. Supra-malleolar fracture 

355. Diagram of Pott's fracture 

356. Displacement in Pott's fracture . 

357. 358. Vicious union after fracture of the fibula 

359. Dupuytren's splint . . . 

360. Fracture of the calcaneum 



PRACTICAL TREATISE ON FRACTURES. 



CHAPTER I. 

By Fracture, in the surgical sense of the term, is meant the breaking 
of a bone or cartilage. 

The liability to fracture of the different bones of the body varies 
greatly in consequence of their differences in size, shape, and degree of 
exposure to external violence or extreme muscular action. Hospital 
records covering periods varying in length from five to eighty-seven 
years, have been tabulated by different writers, with the object of deter- 
mining accurately the relative degree of this liability, and the data thus 
obtained have served as the basis of most of the opinions current upon 
this point. 

It is evident that such statistics cannot present accurately the desired 
facts, for the reason that many of the cases of simpler, less important 
fractures do not need or seek treatment in a hospital. Gurlt, who pub- 
lished in 1862 a most valuable work upon fractures, unfortunately left in- 
complete, collected six sets of hospital statistics published by other au- 
thors, and three sets, one of them being his own, of combined hospital 
and dispensary practice. The differences are notable, and if Malgaigne's 
list be taken as the type of one and Gurlt's as the type of the other, 
it appears that the principal difference is in the relative number of the frac- 
tures of the upper and of the lower extremities, Malgaigne giving in a 
total of 2347 cases 921 fractures of the upper extremity, including the 
clavicle, and 1024 of the lower extremity, while Gurlt gives in a total 
of 1631 cases 805 fractures of the upper extremity and only 569 of the 
lower. 

The following table is the one above referred to, of hospital and dis- 
pensary patients, and is taken from Gurlt. 1 

1 Gurlt, Handlruch. der Lehre von den Knoclienbriichen, 1862. 



34 



FRACTURES. 



Statistics of Fractures Treated in Hospital and Dispensary. 





Lousdale, 










London. 


Blasius, 


Gurlt, 






Middlesex 


Halle, 


Berlin. 




Bones. 


Hospital, 
1831-37. 


1831-56. 


1851-56. 


Total. 


Cranium ... 


481 

13 ' 94 
1 f head. 


17] 
8 1 42 
6 f head. 

HJ 


r-51 

11 1 89 

•H j head. 

13J 


1201 


Nose . 


32 i 225 
17 f head. 


Sup. max. and zygoma 


Inf. max 


32J 


56J 


Vertebral column 


-L ' 392 
3 °l 1" trunk. 

ISJ 


4] 


H 


211 


Pelvis 

Ribs 

Sternum , 


3? L 54 

1 j trunk - 


16 1 158 
104 f trunk. 

25 J 


30 rnJ 

49 S L 604 
4b ° f trunk. 


Scapula . . . . 


4J 


47J 


Clavicle . 


273 "1 


113 




123 




509 




Neck of humerus 


13) 




15 1 




57 ) 




861 v 
219 UlO 

106) 




Shalt 


59 > 118 




5.5 S 76 




75 } 216 






Condyles .... 


16 J 


893 


6$ 


419 


S4) 


S05 


2117 


Forearm .... 


931 

197 Urr 
66 f 3S6 
30 J 


upper 


691 


^ upper 


1371 


upper 

'extrem- 

ity. 


299 1 


upper 
^extrem- 
ity. 


Radius 

Ulua 


"extrem- 
ity. 


26 \lQo 


extrem- 
ity. 


1\>S 1 

28 h 309 


Jg [-860 

59 J 


Olecranon .... 




13 j 




16J 






Metacarpal .... 


50 




20 




34 




104 




Phalanges .... 


66 J 




45 J 




123 J 




234 j 




Neck of femur . . ) 
Shaft and condyles . $ 


181 fern.] 


Sj ^ 




156 j 232 ' 




510 




Patella .... 

Leg 

Tibia 

Fibula . . . . . 


i 3S 5<>2 
\ l l' (289 1 lower 
51 S le ^ | extrem " 


20 

30 ( 139 
15 ) 


263 

lower 

extrem- 


2-? 

1731 
g ^83 


569 

lower 

^extrem- 


80 
4641 

107 L'7il 

108 f ' il 

32 1 


1354 
lower 

extrem- 


Malleoli .... 


.. ' ity - 




ity. 


32j 


ity. 


ity. 


Tarsus and metatarsus 


.3 


*7 




23 




33 




Phalanges .... 


11 J 


J 




9 J 


20 j 




Unknown . 






10 


10 












1901 


778 


1631 


4310 



Shortly afterwards Gurlt 1 published the following table made up from 
twenty annual reports of the London Hospital. Its numbers are much 
larger than those of any other collection, but the details are somewhat 
scanty. So far as it goes it confirms Gurlt as against Malgaigne. 



Laugenbeck's Archiv, 1862, vol. iii. p. 394. 



FRACTURES. 



35 



Fractures in London Hospital 1842-1862. 



Ia Hospital. 


" Out-patients." 


Total. 


Head, S 296 skull 

630 I 334 bones of face .... 

( 74 spine 

m -, 70 pelvis 

Jrunk, i r>- nA ., 

3032 2 ™ribs 

20 sternum .... 
[ 78 scapula . . . . . 

yr , f 285 clavicle ..... 

i .. i 546 humerus .... 
extremitv, < OOA f 

ifidA i 3b4 forearm 

10 " 4 1, 419 hand 

T f 1373 femur ..... 

J j0wei ; 302 patella 

extremitv, < 9Q9 i, f 

5440 ^ 333/ le § 

D44U t 428 foot 


192 I 204 

1 1 
3 i 

1044 j> 1,202 

2 I 
152 j 

3182 1 

}!?? [10,285 
411o f 

1883 J 

811 

8 2 [ 239 

71 j 


mi ^ 

75 1 

73 | 

3834 }■ 4,234 

22 j 

230 J 

3417 1 

4499 | ^ 
2302 J 

1454 1 

34 19 \ 5 ; 6 ' 9 
499 J 


Totals 10,686 


11,930 


22,616 



He followed this in 1880 1 with the following table made up from the 
records of the same hospital from 1842 to 1877 
very close. 



The agreement is 



Fractures Treated in the London Hospital 1842-1877. 





Hospital. 


"Out-patients." 


Total. 


Per cent. 




Skull .... 
Face .... 


730 
732 


27 
513 


757 
1.245 


1.457 1 
2.397 j 


Head 2002 
3.854 per ct. 


Spine .... 

Pelvis .... 

Coccyx 

Ribs .... 

Sternum 

Scapula 


169 

139 

5 

4,7S4 

45 

135 


3 

3 

10 

3,477 

290 


172 

»? 

15 

8,261 

52 

425 


0.331 1 
0.273 | 
0.028 : 
15.905 f 
0.1 | 
0.818 J 


Trunk 

9067 

17.457 per ct. 


Clavicle 

Arm .... 

Forearm 

Hand .... 


382 

1,064 

709 

856 


7,458 
3,020 
8,731 
4,899 


7.840 
4,084 
9,440 
5,755 


15.094 1 

7.S63 ' 

18.175 f 

13.080 J 


Upper 

extremity 

27,119 

52.214 per ct. 


Thigh .... 

Patella 

Leg .... 

Foot .... 


3,072 

649 

8.067 

965 


171 

15 

256 

555 


3,243 

664 
8.323 
1,520 


6.243 1 

1.278 ! 

16.024 f 

2.926 J 


Lower 

extremity 

13,750 

26.473 per ct. 




22,503 


29,435 


51,938 



The relative frequency of fractures as compared with other surgical 
injuries is shown by the following facts. During the same period there 



1 Langenbeck's Archiv, 1880, p. 466. 



36 FRACTURES. 

were treated in the same hospital, 5212 dislocations, 98,373 wounds, 
23,180 contusions, 39,917 sprains, 20,396 scalds and burns, 3715 dog- 
bites, and 975 suicidal attempts. 

Sex. — All statistics show that fractures are more numerous in men 
than in women, in the proportion of about three to one, taking all cases, 
but this proportion varies greatly at different ages. In infancy the dif- 
ference is slight ; in middle life fractures are ten times as frequent in 
men as in women ; between the ages of fifty and seventy years the dif- 
ference again becomes slight ; and after the age of seventy fractures are 
much more common in women than in men, a reversal of conditions due 
to a disproportionate increase in the number of fractures of the neck of 
the femur. 

Age. — Tabulation of the fractures contained in Gurlt's table, with 
reference to the ages of the patients, shows in the first decade 265 ; in the 
second, 193 ; in the third, 274 ; in the fourth, 224 ; in the fifth, 154 ; 
in the sixth, 155 ; in the seventh, 72 ; in the eighth, 38 ; and in the 
ninth, 8. These figures are far from expressing the relative frequency 
of fracture at the different ages, unless they are considered in connec- 
tion with others showing the relative number of people living at the 
different periods. Malgaigne did this with accuracy, and, comparing 
successive periods of five years, found that the period between the ages 
of fifty -five and sixty furnished the largest number of fractures in pro- 
portion to population. It must be borne in mind, however, that his 
statistics included only hospital cases. Gurlt's corresponding estimate 
gives the highest proportion of fractures to the period above sixty years 
of age. He further attributes the frequency of fracture in early child- 
hood to rachitis ; an opinion which does not appear to be shared by 
other writers. 

Season. — Ambroise Pare declared that the bones were more fragile 
when the temperature of the air was below the freezing-point than at 
other times, and this opinion has been generally held since his time to 
the extent, at least, of believing that fractures are more common in winter 
than in summer. Malgaigne overthrew the claim by statistics, except as 
regards women, who show an increase of nearly one-third in the winter. 
Gurlt's statistics show that the difference between the two seasons is 
very slight, and do not confirm Malgaigne's statement concerning the 
greater frequency in women in winter. 



VARIETIES OF FRACTURE. 37 



CHAPTER II. 

VARIETIES OF FRACTURE. 

The varieties of fracture are numerous and are constituted by differ- 
ences in the extent of the injury to the bone, or to the surrounding soft 
parts, in the seat and direction of the fracture, in the relation of the 
fragments to each other, and in the number of bones involved. These 
varieties may be grouped in five divisions, marked by important clinical 
differences and containing many subdivisions, as follows : — 

1. Incomplete fractures. 

(a) Fissure. 

(6) True, incomplete, "green-stick" fracture ; bent bone. 

(c) Depressed. 

(c?) Separation of a splinter or of an apophysis. 

2. Complete fractures, subdivided according to — 

(a) Direction of the line of fracture into transverse, oblique, 
longitudinal, toothed or dentate, and V-shaped. 

(5) Seat of the fracture, into fracture of the shaft of the bone, 
of the neck of the bone, of the epiphysis, intercondyloid, 
separation of epiphysis ; and, 

(c) If communicating with a joint, intra-articular. 

3. Multiple fractures, comprising fractures of two or more different 

bones, two or more fractures of the same bone at different points, 
comminuted or splintered fractures, impacted fractures, and frac- 
tures with crushing. 

4. Compound fractures. 

5. Gunshot fractures. 

The term simple fracture, when used in its strictly technical sense, 
means that the bone is broken at only one point ; but it is also in com- 
mon use, in contradistinction to the term compound, to indicate that there 
is no associated wound of the soft parts which establishes communication 
between the fracture and the exterior. Some writers make also a class 
of complicated fractures to include cases in which, in addition to the 
fracture itself, there exists some other important injury, such as the rup- 
ture of a nerve or of an artery, or the laceration of a joint ; and there 
are still other terms in use to indicate peculiarities which do not lend 
themselves easily to the above classification. Such are : Spontaneous 
fracture, a fracture produced by the minimum of violence ; pathological 
fracture, a fracture due to previous partial destruction of the bone by a 
tumor ; recent, and old, or ununited, fractures. This classification is 
not claimed to be absolutely correct in the scientific or even in an ana- 



88 



VARIETIES OF FRACTURE. 



tomical sense, but it is a serviceable one, and one recognized by all 
writers, although some of the subdivisions are differently placed. 



1. Incomplete Fractures. 

Under this head will be considered fractures of long bones, in which 
the continuity of the bone has not been completely lost, and fractures of 
flat bones in which the line of fracture does not extend from one side to 
the other. 

(a) Fissures. — This variety of incomplete fracture is characterized by 
the existence of a split or crack of variable length and depth in the bone, 
one which does not entirely circumscribe a fragment and separate it 
from the rest of the bone. It is of common occurrence in the bones of 
the cranium, not very infrequent in the ribs, and very rare in the long 
bones, except when associated with other varieties. In the latter case, 
and when the sides of the fissure are somewhat separated from each 
other, it is sometimes described as a longitudinal fracture. When sev- 
eral frssures radiate from a central point at which there is usually con- 
siderable splintering, depression, or crushing, the injury is called a 
"starred" or " stellate" fracture. 

The existence of this form of fracture in the flat bones, and especially 
in those of the cranium, has been admitted since the time of Hippocrates. 
Every pathological museum contains examples of it. In the short or 
spongy bones it is so rare as to be almost unknown, and it is only of late 
years that its occurrence in the long bones has been positively demon- 
strated. This rarity may be due in part to the dif- 
Fig. l. ficulty of diagnosis when the bone is not exposed 

to view. A simple fissure of the skull, for example, 
often passes unrecognized by the finger or the eye 
until after the peritoneum covering it has been re 
moved. 

Fissures occur frequently in the long bones in 
connection with complete fracture, are sometimes 
very long, and may extend into a neighboring joint. 
They always involve the entire thickness of the com- 
pact substance. They are commonly found in con- 
nection with gunshot fractures, and with those pro- 
duced by great violence, as in falls from a height, 
and they constitute an important complication in the 
Y-shaped fractures of the tibia. 

The examples of simple fissure of long bones un- 
connected with complete fracture are very rare, but 
are demonstrative of the fact. Fig. 2, copied by 
Fissured fracture. Gurlt from Froriep, represents a linear fracture or 
fissure extending from the greater tuberosity of the 
humerus down to the lower fourth of the shaft, produced in a boy by a 
fall upon the elbow. Four other cases in which the nature of the injury 
was established by examination of the specimen immediately after the 
occurrence presented similar, well-defined fissures ; one of the humerus, 
two of the radius, and one of the tibia. These cases are amply sufli- 




INCOMPLETE FRACTURES. 



39 



Fig-. 2. 



cient to prove the possibility of this form of fracture without the aid of 
Malgaigne's clinical proofs, which are not all entirely 
beyond suspicion as to the correctness of the diagnosis. 

The mechanism by which the fissure is produced in 
long bones, in those cases in which it exists alone, is not 
definitely known. In two of the cases mentioned above, 
the immediate, exciting cause was extreme violence ex- 
erted upon one end of the fractured bone in a direction 
parallel to its long axis ; this is suggestive of a possible 



in " green-stick' 1 



begins at one 



fracture, with 
end and 



bending of the bone as 

this difference, that the fracture 

not in the middle. 

This mechanism is shown very plainly in a case re- 
ported by Debrou in 1843, and quoted by Gurlt as a case 
of infraction or bent fracture. The patient, a man sixty- 
two years old, fell while walking, and injured his thigh. 
Ei^sipelas set in and caused his death. At the autopsy 
a fissure was found under the unbroken periosteum ex- 
tending six inches downward from the trochanter minor, 
and this fissure could be made to widen by pressure upon 
the ends of the bone. 

The diagnosis cannot be made with certainty, except 
when the bone is exposed to direct examination through 
a wound of the overlying soft parts ; but it can be in- 
ferred with much probability in some forms of fracture of 
the limbs with which it is usually associated, such as perforating gunshot 
wounds and Y-shaped fractures of the tibia, and from the symptoms in 
fracture of the skull. 

Except in the bones of the cranium, or when it extends into a joint, 
the importance of a fissure is probably slight, and is dominated by that 
of the associated lesions. It heals, as do other fractures, by bony or 
fibrous union. In some cases the injury has been promptly followed by 
suppuration within the bone and a train of consequences ending in 
death or amputation; in others, suppuration has been discovered two or 
three months after the injury, under the periosteum, or within the medul- 
lary canal, under circumstances which make it probable that it was due 
rather to direct contusion of the bone than to the fissure itself. The 
extension of a fissure into a joint is a serious complication. 



Fissure of the 
humerus. (Gurlt.) 



(])) True incomplete, " green- stick" fracture; bent bone. 

Syn. Fractura incompleta, Infractio. Infraction, Curvature without 
fracture. 

This variety is characterized by a fracture involving only a portion of 
the thickness of a long bone, and combined with a bending of the bone 
at the seat of the fracture. It is male by some authors to include also 
depressions or partial fractures of flat bones, a variety which will be 
considered in the next section. It includes also the rare cases of simple 
curvature without recognizable fracture. 

It has been objected that a rigid material like bone cannot undergo a 
sudden, violent, and permanent change of form without fracture of all 



40 



VARIETIES OF FRACTURE. 



its fibres at the point where the change takes place. The objection is 
a purely verbal one. It may be, and probably is, true that no perma- 
nent change of form can occur without some shifting of the relations 
between the minute elements, but so long as this, shifting cannot be recog- 
nized by the means at our disposal, so long as the continuity of the bone 
is actually preserved, it cannot be said that a fracture exists. 

As a matter of fact, ascertained by post-mortem examination and by 
experiments upon animals and upon cadavers, there exist all degrees of 
change between simple curvature without recognizable fracture at any 
point and complete fracture. Anatomically a distinction may be made 
between simple curvature and partial fracture, but clinically the distinc- 
tion does not exist. Simple curvature has been produced experimentally 
in young animals, and occasionally, but very rarely, upon the bodies of 
young children in the fibula when the tibia has been broken. A clinical 
and post-mortem demonstration of its occurrence has never been made, 
if we except a single specimen belonging to Prof. Uhde, of Brunswick, 
the ulna of an adult much bent by a machinery accident, and showing 
no trace of fracture. This specimen is mentioned by Gurlt, but without 
details. After most attempts to produce this variety of fracture expe- 



Fiff. 3. 





Partial or green-stick fracture of 
the radius. 



Partial fracture of the 
fibula, a, the head ; 
b, the malleolus. 



Partial fracture 
of the fibula. 



rimentally, careful examination shows a number of minute fractures at 
the point of greatest curvature. Ordinarily, partial fracture appears 
as a short transverse fracture, continuous with one or more longitudinal 
ones of variable length; sometimes there is no transverse line of frac- 



INCOMPLETE FEACTUKES. 11 

ture, but only oblique ones running from the point of greatest curvature 
upwards or downwards along the shaft of the bone. The appearance 
can be very closely imitated by over-bending a green or tough stick, a 
fact that has given this form of fracture the name by which it is very 
commonly known. The periosteum may or may not be broken at the 
point or along the line of fracture. 

A few instances are recorded of supposed incomplete fracture of the 
neck of the femur. Here the mechanism and appearance of the fracture 
are quite different in consequence of the spongy character of this portion 
of the bone. The line of fracture is transverse and upon the concave 
side, and is produced by crushing, not by over-bending. 

This fracture is seen most frequently in the bones of the forearm, then 
in the clavicle, and very rarely in the bones of the leg, arm, and thigh. 
In the forearm the convexity in the great majority of cases is upon the 
outer side, and the injury is usually the result of a fall upon the hand. 
It occurs almost exclusively in children, and between the ages of 1 and 
11 years. In a case which came under my care in 1882, the patient 
was a large stout youth of 18. His hand had been caught in machinery, 
and the forearm twisted about a large shaft ; the concavity of the curve w r as 
on the anterior and outer side, and I was unable to straighten it entirely. 

The chief symptom is deformity, consisting in a more or less marked 
change in the outline of the limb or bone, a change that can be modified 
by pressure at its most prominent point, but without crepitation and 
without abnormal mobility, except sometimes in the plane of the curve 
itself ; in the forearm, for example, the mobility is in the direction of 
flexion and extension, but is not lateral. There is also localized pain at 
the seat of the fracture. It is conceivable that this fracture might be 
produced, and that the elasticity of the bone might be sufficient to restore 
its shape immediately. The only means of diagnosis in such a case 
would be the localized pain and the history of the injury. 

The prognosis is favorable as regards healing and relief of deformity. 
Ordinarily, pressure upon the prominent point, with or without moderate 
extension, will overcome the deformity, and it has been observed in some 
cases where this could not be completely accomplished at the time that 
spontaneous restoration of form occurred within a few months. In some 
cases the deformity cannot be overcome, the bone cannot be straightened, 
because, apparently, the fragments have become so interlocked as to 
oppose a mechanical obstacle sufficient to neutralize all the force that it 
was considered justifiable to apply to the reduction. In Malgaigne's 
case he evidently, though unintentionally, transformed the partial frac- 
ture into a complete one, and I can see no reason why this should not 
always be done if necessary to obtain reduction when the deformity is 
great. If the unrelievable deformity is slight, we may safely trust to 
continuous elastic pressure by means of a splint and a roller or rubber 
bandage. 

It is not necessary that splints or other apparatus should be worn for 
the same length of time as in cases of complete fracture. The unbroken 
portion of the bone acts as a splint, and prevents displacement, but the 
same precautions must be taken against a too early or incautious use of 
the limb. 



42 VARIETIES OF FRACTURE. 

(/?) Depressions. 

These are incomplete fractures of flat bones, not involving the entire 
thickness, and accompanied by a bending of the unbroken portion, and 
a depression of the surface. The most frequent examples are presented 
by the cranial bones of new-born or young children ; the fracture is on 
the side towards which the bone is bent, and is accompanied by one or 
more fissures involving the entire thickness. Malgaigne applies the term 
also to partial fracture of the ribs, where the fracture is on the outer 
side, and is produced by crushing. The importance of the injury is 
generally due to accompanying lesions of the contained viscera, the 
brain, and the lungs in the cases just mentioned, and under such cir- 
cumstances the therapeutic indication is to raise the depressed portion 
of bone. (These must not be confounded with depressed fractures of 
the skull, in which the entire thickness of the bone is broken and 
driven in.) 

(c?) Separation of a splinter or of an apophysis. 

In this variety are included two classes of fractures, which differ 
widely in their mode of production, but have this in common that the 
fragment does not comprise the entire breadth or thickness of the bone, 
and that consequently the continuity of the latter is not destroyed. In 
the first class a splinter or fragment of bone is broken off by direct 
violence, often by a cutting instrument or by a bullet; in the second 
class a bony prominence is torn off by the violent contraction of the 
muscle or muscles attached to it. 

The separation of a splinter or scale of bone by a sword-cut or bullet 
is not uncommon in the spongy bones or the spongy extremities of long 
bones, and has also been known to occur in the shaft of the tibia. It 
is an injury which should be classed rather among wounds of bones than 
among fractures. The separation of a splinter by direct violence, unac- 
companied by a wound of the soft parts, occurs in the bones of the 
face, at the crest of the ilium, and at exposed points upon the extremi- 
ties of the long bones. Malgaigne produced it once experimentally upon 
a rib, breaking off a piece from the lower border, and he quotes from 
Dandifort the description of two specimens of splinters of the shaft of 
the femur, one an inch and a. half, the other four inches in length. 
There is no record of the manner in which the injury was produced, and 
the specimens were obtained after repair had taken place. 

Avulsion of an apophysis, or of a scale of bone, by muscular action, is 
a far more common accident than the one just described. The lesion 
consists in the fracture of an apophysis at its base, or in the tearing off 
of a portion of bone to which a muscle or tendon is attached. The frag- 
ment may consist of a thin layer of bone corresponding in extent to the 
muscular attachment and composed almost exclusively of the cortical 
substance, or it may comprise the entire thickness of an apophysis, as in 
fracture of the olecranon, of the coronoid process of the ulna, or of the 
coracoid process of the scapula. In like manner either malleolus may 
be torn off by forcibly bending the foot to the opposite side, or a condyle 
or epicondyle at the elbow or knee by forced lateral flexion of the fore- 
arm or leg, the force being exerted through the lateral ligaments. 



COMPLETE FRACTURES. 



43 



2. Complete Fractures. 

The terra complete, when applied to a fracture of a long bone, indicates 
that the bone is divided into two or more distinct fragments by a line of 
fracture crossing its long axis. 

(a) The subdivision according to the direction of the line of fracture 
has led to .much discussion, of which a large part has been wasted upon 
verbal subtilties. The old division was into transverse, oblique, and 
longitudinal fractures, names which convey the associated ideas with 
sufficient distinctness. Malgaigne undertook to limit the term transverse 
to fractures crossing the shaft of a bone at right angles to its axis — and 
presenting no marked irregularities- of outline or of surface, such a frac- 
ture, for example, as would be obtained by breaking a radish, a com- 
parison from which one of the names of this variety, fracture en rave, 
was obtained. He said he had not been able to produce such a fracture 
experimentally and had not found a specimen of one in any of the patho- 
logical museums he had examined. He claimed, therefore, that such a 
fracture did not exist, except in certain spongy bones or apophyses, such 
as the acromion, inferior maxilla, and patella, and that those which had 
been described as such were either oblique or toothed. 

The same observation had been made nearly a century before by 
Camper, as Malgaigne himself subsequently pointed out, and there can 



Fig. 6. 



Fig. 7. 





Transverse fracture of the femur. 
(Gurlt ) 



Transverse fracture of the femur. (Gurlt.) 



be no doubt but that the line of the so-called transverse fractures, is, in 
general, oblique and irregular, as claimed by these authors. But, on 
the other hand, they erred in being too absolute, for Gurlt has repre- 



44 



VARIETIES OF FRACTURE 



sented in his subsequent work several specimens, two of which are cer- 
tainly entitled to be called transverse fractures of the shaft of the femur 
in the strict sense of the term (figs. 6 and 7), and a third is a transverse 
fracture through the head of the tibia with splitting of the articular end. 
Gerdy has also described and figured a similar specimen. The variety, 
in the strict sense of the term, is, doubtless, very rare, but its existence 
cannot be denied. It merges into the oblique variety by changes in the 
general direction of the line of fracture, and into the toothed or dentate 
variety by increase in the size of the irregularities upon its surface. 
Clinically, a transverse is distinguished from an oblique fracture by the 
fact that its general direction is transverse, and prevents overlapping of 
the fragments, unless there is also associated with it a lateral displace- 
ment equal to the diameter of the bone ; and from a toothed fracture by 
the greater abnormal mobility, crepitation, and ease of reduction. 

Irregularities of outline, due to the presence of prominences of vary- 
ing height and breadth of base, are found in all fractures of the shaft of 
long bones, as might be expected from a consideration of their irregular 
shape and the variations in the thickness of their cortical layer. It is 
only when these prominences are sufficiently large to 
Fig. 8. seriously affect the degree of displacement of the 

fragments and the possibility in the completeness of 
the reduction that they deserve to be considered as 
constituting a distinct variety, the toothed fractures. 
The fact that these teeth or prominences may become 
so wedged together by the violence that causes the 
injury, that, notwithstanding the completeness of the 
fracture, its usual signs may be greatly diminished, 
or even entirely absent, is of especial importance. 
There may be no abnormal mobility, crepitation, or 
recognizable displacement, and this may lead to an 
erroneous diagnosis of simple contusion or incomplete 
fracture. It is more commonly the case, however, 
that some of the prominences are broken off, consti- 
tuting splinters, and that there is an incomplete sepa- 
ration of the fractured surfaces, a separation which it 
is always difficult and sometimes impossible to over- 
come completely on account of the interlocking of the 
smaller fragments and the prominences. 

This variety is produced more frequently by direct 
than by indirect violence or muscular action. In ex- 
periments upon cadavers it has been found that frac- 
tures produced by a heavy blow upon the shaft of 
the bone were invariably toothed and usually splin- 
tered. This fact is of value in the diagnosis, the 
difficulties of which have been already mentioned. 
In the difficult cases anassthesia may be employed 
with advantage both for making the diagnosis and 
Toothed fracture correcting the displacement, but it must be remem- 
of the femur. berecl that unless displacement exists forcible handling 



COMPLETE FRACTURES 



45 



of the parts with the object only of making an accurate diagnosis is not 
justifiable. Moderate force exerted by the hands, may be properly 



Fig. 




Fig. 10. 



Fig. 1: 



Toothed fracture of the tibia. 

employed to overcome deformity, even if it results in the fracture of 
some of the prominences, for the splinters thus produced usually remain 
adherent to the periosteum and thus preserve 
their vitality, and do not interfere with re- 
covery. 

The V-shaped fracture of the tibia, first 
described by (xosselin, 1 is an important 
variety of toothed fractures. The injury is 
generally situated in the lower half, or even 
the lower third, of the leg, and is character- 
ized by a large Y-shaped prominence upon 
the anterior and inner margin of the lower 
end of the upper fragment, and a similar one 
upon the posterior margin of the upper end 
of the lower fragment. From the depres- 
sion or re-entrant angle in the lower frag- 
ment, which corresponds to the first-men- 
tioned prominence, one or two fissures pass 
spirally downwards and often enter the 
ankle-joint. It is this fact, together with 
the difficulty of making the reduction and 
of maintaining it when made, that gives this 
variety its importance. It will be described 
more fully in connection with the other frac- 
tures of the tibia. 

An oblique fracture of a long bone is one 
in which, as the name so plainly indicates, the y. s]ia p ed fracture 
direction of the line of fracture is interme- 
diate between the longitudinal and trans- 
verse axes of the shaft. Generally speaking, fractures whose direction 



Oblique fracture 
of the humerus. 



1 Memoires de la Societie de Chimrgie, torn, v., 1855. 



46 VARIETIES OF FRACTURE. 

does not vary more than 15° or 20° from either axis are not included 
under this term ; they are classified respectively with the transverse and 
longitudinal fractures. When the deviation from the transverse axis is 
more than 45°, the fracture is named by the French authors from its re- 
semblance to the mouth-piece of a clarionet, fracture en-bec-de-fiute (fig. 
12), a fact which deserves mention only on account of the frequency with 




Oblique fracture of the clavicle. 

which the term is encountered in surgical literature. The less the obli- 
quity of the fracture, that is, the more nearly it approaches the trans- 
verse axis of the bone, the more numerous and prominent are the irregu- 
larities upon its surface and the more nearly does it coincide with the 
toothed fractures above described. The obliquity is greater when the 
fracture has been produced by indirect violence, and the smoothness of 
the surface of the more oblique fractures harmonizes, therefore, with the 
observation previously made, that toothed fractures are usually caused by 
direct violence. The greatest degrees of obliquity are found in the 
femur, tibia, and clavicle, more rarely in the arm and forearm, except, 
perhaps, just above the elbow. The especial clinical importance of the 
variety is found in the tendency of the fragments to over-ride, to undergo 
longitudinal and lateral displacements. 

Longitudinal fractures are those in which the direction of the line 
of fracture corresponds more or less accurately to that of the longitudinal 
axis of the bone. Bouisson, and after him Gurlt, have called attention 
to the fact that a division of this class into two varieties based upon 
pathological differences has an important corresponding clinical signifi- 
cance. The simplest and least dangerous kind is one that might be 
called an extremely oblique fracture, one whose direction is nearly par- 
allel to the long axis although it crosses the bone (fig. 13). The other 
and more serious kind, is that in which the main line of fracture is more 
exactly longitudinal, and terminates at one or both ends in a transverse 
or oblique line. The reason of this difference appears on examination 
of the different lesions and of the manner in which they are produced. 
Bouisson 1 produced experimentally the completest, most typical, form of 
longitudinal fracture, one running the entire length of the bone, and 
gives a figure of one in the plates attached to his work, but there is no 
record of such a fracture produced during life and verified by autopsy. 
The nearest approach to it seems to be one reported by Cloquet in 1831, 
and quoted by most subsequent writers upon the subject. The patient 

1 L'Union Medicale, 1850, and Tribut a la Chirurgie, vol. i. p. 1. 



COMPLETE FRACTURES, 



47 



fell from a roof and fractured his femur, the fracture extending from the 
intercondyloid notch to the trochanter minor; it was exactly longitudinal 
in the lower four-fifths of its length, and then deflected to terminate on 
the inner surface of the bone. A case remarkable on many accounts, 



Fig. 13. 



Fig. 14. 





Oblique fracture of the femur. 



Longitudinal fracture of the tibia. 



and apparently a longitudinal fracture of the most perfect type, was 
treated in the service of Professor Rose at Zurich, and the account pub- 
lished by his assistant, Kronlein, 1 in a paper on longitudinal fractures. 
The patient was a man, 27 years old, who received his injury in trying to 
raise a heavy ladder. The right humerus was fractured longitudinally, 
presumably through the torsion exerted by the muscles, the fracture 
running from the shoulder joint to the elbow joint. The man continued to 
work for four days ; the pain and the swelling increased, and he entered 
the hospital about a week later. Fluctuation became evident in the course 
of the second month, and evacuating incisions were made at the upper 
and lower end of the arm, through which the fracture was felt. The 
edges of the fracture became necrosed, several long sequestra were cast 
off, and the patient after passing through many complications was dis- 
charged cured at the end of two years. Both joints were firmly anky- 
losed. 

Among Bouisson's personal cases the most remarkable on many 
accounts is one that may serve as an example of the second or more dan- 
gerous kind. A man, 21 years of age, was crushed by a falling stone and 



» Deutsche Zeitschrift fur Chir., 1873, p. 132. 



48 VARIETIES OF FRACTURE. 

sustained, together with other injuries, a fracture of the femur. Three 
weeks after the accident the limb became gangrenous and amputation was 
performed high up. The femur was found to be fractured transversely 
at two points, one in the lower third, the other just below the trochanter 
minor, and the intermediate piece, which was eight inches long, was split 
longitudinally. The patient recovered. Bouisson's experiments were 
all made upon dried bones, either by subjecting them to extreme violence 
applied laterally along some prominent ridge or edge by means of a 
heavy mallet or a vise, or, in imitation of a gunshot injury, by driving 
a wedge or large nail into them. Laforgue obtained similar results by 
blows upon the lower end of the femur and upper end of the tibia in the 
direction of the long axis. The possibility of the fracture is thus estab- 
lished both clinically and experimentally, and can no longer be called in 
question. 

The simpler form is produced usually by indirect violence, and is ac- 
companied by but little splintering ; the greater gravity of the other 
form seems to be due to the direct violence which causes it, to the 
splintering, and to the crushing or bruising of the marrow, conditions 
which favor extensive suppuration, and, if the fracture is compound, will 
probably render amputation of the limb necessary. In only one of the 
cases collected by Gurlt did the patient save both limb and life, and 
in that case the fracture was purely longitudinal, without splintering, 
and without displacement. 

The diagnosis even in the simpler form may be difficult unless the 
bone is so nearly subcutaneous that the outline of the fragments can be 
felt. In the severer forms it is often impossible to this extent, that while 
the transverse fracture at either end may be distinguished, the interme- 
diate longitudinal lines may escape detection. When there has been 
much splintering, a probable diagnosis may be made by attention to the 
nature of the violence that caused the injury, the extensive swelling of 
the soft parts, the distribution of the pain over a considerable portion of 
the bone, the absence of angular displacement or of shortening, and peculi- 
arities in the position where crepitation is found and the manoeuvres by 
which it is obtained, which may indicate the extent of the fracture. 

There are no special indications for treatment except that in the 
severer cases the probable necessity of amputation must be borne in mind, 
and a decision, based upon the circumstances of each case, must be 
reached as promptly as possible 

(5) Varieties dependent upon the seat of the fracture. A fracture 
may occupy any portion of the bone or of its apophyses, and be known by 
the name of the portion fractured : thus, we speak of fractures of the 
neck of the femur, of the lower third of the tibia, of the shaft of the 
humerus, of the internal malleolus, of the outer or inner condyle, and of 
the acromion. When the fracture extends across the expanded lower end 
of the humerus or of the femur, and also downwards between the con- 
dyles into the joint, it is called inter condyloid (fig. 18), and when it 
follows, in children or adolescents, the line of the conjugal cartilage 
between the shaft of the bone and the epiphysis, it is called a separation 
or a disjunction of the epiphysis. Only the last one requires special 



COMPLETE FRACTURES. 49 

description here, intercondyloid will be spoken of in connection with the 
intra-articular fractures. 

Separation of the epiphysis. — Under this term I shall consider here 
that class of cases in which, ossification not yet having been completed, 
a transverse fracture separates the shaft of a long bone from one of its 
epiphyses. At birth the epiphyses of the main bones of the extremities 
are wholly, or almost wholly, cartilaginous, and are somewhat longer in 
proportion to the shaft than they are at the time when ossification be- 
comes complete. The line of demarcation between the epiphysis and 
the shaft is transverse, except where it is modified by the presence of 
unossified tuberosities upon the outer surface of the bone. Thus, at the 
lower end of the humerus the line bends upward to include in the epi- 
physis the outer and inner epicondyles, and at the upper end of the tibia 
it sends a tongue-shaped process downward on the anterior surface to 
include the tuberosity. Ossification begins in these epiphyses by one or 
more central points, and extends peripherally until it occupies all but a 
narrow line of cartilage at the junction with the shaft. This line is 
called the conjugal, or epiphyseal, cartilage, and the subsequent growth 
of the bone in length takes place upon its central (diaphyseal) surface. 
The surface of union between the epiphyseal cartilage and the shaft is 
apparently uniform, but the union is strengthened 
by minute interlacing prominences in such manner ff * " 

that when an epiphysis is violently separated — 
portions of the shaft of greater or less size, usu- 
ally mere scales of bone, are torn off with it. 
This fact furnishes an additional reason, if one is 
needed, for including this lesion among fractures. 
The period at which bony union between the shaft 
and the epiphysis becomes complete varies with 
the epiphysis and with the individual. The epi- 
physes Which form the elbow-joint Unite before Separation of the lower 
f * . J . epiphysis of the femur. 

those which torm the upper extremity ol the (Bryant.) 
humerus and the lower extremity of the radius ; 

while those which form the knee-joint remain ununited longer than those 
at the opposite ends of the same bones. In females all are united, as a 
rule, by the 22d year ; in males, by the 24th or 25th, yet instances are 
not lacking in which the conjugal cartilage has persisted until a much 
later period. 

Many experiments have been made to determine the degree and direc- 
tion of the force necessary to produce this fracture, and to supplement 
the scanty clinical data concerning its pathology and symptoms. In the 
very interesting chapter which Gurlt devotes to the subject may be found 
abstracts of the results obtained by different experimenters. Gurlt him- 
self was unable to separate any of the epiphyses by direct traction, as 
others had done, but he found no great difficulty in accomplishing it in 
children less than a year old by forced flexion or extension of the joint, 
especially of those joints where the normal range of motion is limited, 
the elbow and knee. He was also able to produce it by fixing the epi- 
physis, and bending the shaft in the antero-posterior, or in a lateral 
direction. In the bodies of older children he found it much more diffi- 
4 




50 VARIETIES OF FRACTURE. 

cult. Salmon 1 produced experimentally complete and incomplete sepa- 
ration, both with and without accompanying fracture of the bone. The 
periosteum sometimes remained untorn when there was no displacement 
of the fragments, but usually displacement was accompanied by the 
stripping off from the shaft of a portion of its periosteum, which re- 
mained attached to the epiphysis. The crepitation which can be obtained 
in complete separation has not the sharpness and distinctness of that 
which is found after fracture of bone ; it can be produced at the elbow 
after reduction of the displacement by rubbing the fragments quickly 
backwards and forwards against each other. 

Gurlt, in 1862, could collect only seventeen cases of separation of an 
epiphysis during life in which the diagnosis was verified by dissection ; 
of these, five were of the humerus (4 of its upper and 1 of its lower 
end), four of the lower end of the radius, five of the lower end of the 
femur, and three of the tibia. He expresses the opinion that this is a 
rare accident, and attributes its rarity to the fact that children are seldom 
exposed to the action of forces sufficiently violent to produce the sepa- 
ration. The histories of these seventeen cases show that the violence 
was much greater than that which is the usual cause of fracture at the 
corresponding periods of life. In three of the cases the fracture was 
produced during the delivery of the child by traction upon the foot, arm, 
or axilla ; in seven by severe falls ; in five the limb was caught by ma- 
chinery or between the spokes of a wagon wheel ; and in one separation 
of the upper epiphysis of the humerus was produced in a child three 
years old by jerking its arm. With the exception of the three new T - 
born children only one of the patients was less than nine years old; the 
oldest was eighteen. 

On the other hand, the opinion has been held by some that the acci- 
dent was not by any means so infrequent as the rare mention of it might 
indicate, and two papers have been published recently in support of this 
opinion. Vogi 2 reported a case in which the left humerus had become 
thirteen centimetres shorter than its fellow in consequence of an injury 
received at the age of ten years, which was probably a separation of 
the upper epiphysis. He claims that the fracture (separation) without 
displacement is common in early life, and heals promptly in children of 
strong constitutions without leaving any evil consequences, while in the 
weak and strumous it is the frequent cause of suppurative disease of 
the bone. 

Bruns 3 collected eighty-one reported cases in which the diagnosis had 
been confirmed by direct examination of the seat of injury, either 
through an associated wound or after amputation or death. In eleven 
cases the injury was double or multiple ; the total being 101, divided as 
follows : — 

1 Des solutions de continuity trauraatiques des os dans le jeune age. These de 
Paris, 1845. Quoted by Gurlt, 

2 Langenbeck's Archiv, vol. xxii. 1878, p. 343. 

3 Idem., vol. xxviL 1882, p. 240. 



COMPLETE FRACTURES. 51 

TT ( upper end 11 

Humerus { ^ i i 

( lower end -1 

Ulna \ upper end 1 

Ulna \ lower end 2 

Radius lower end 25 

Ossa pubis 3 

^ ( upper end 3 

Femur < lower end 28 



Tibia 



upper end 1 
lower end 1L 



Fibula | upper end 3 

( lower end 1 

Metatarsus 2 

101. 

In 44 cases the patients were between the ages of ten and nineteen 
years, and in 8 between one and nine, the maximum of frequency being 
at about the sixteenth year. Of 61 cases in which the exact description 
of the fracture was given, 23 were purely epiphyseal separations, 5 frac- 
tures through the cartilage, and 33 partly diaphyseal, that is, the line oi 
fracture passed through the " chondroid" tissue at the end of the diaphy- 
sis, a tissue which is partly bone and partly cartilage." 

He argues that if by a rather hurried search he was able to collect 81 
such cases, the number of simple uncomplicated fractures must be very 
much greater, and that the injury is not an uncommon one. 

My personal experience of the subject is limited to 2 cases, both com- 
pound. In one a boy thirteen years old caught his foot in machinery and 
received a compound comminuted fracture of the proximal phalange of 
the great toe ; I could see and feel through the wound the smooth carti- 
laginous disk limiting the epiphysis. The patient made a good recovery 
and had a movable joint. In the other, a child about two years old, the 
upper epiphysis of the right fibula was torn off by the wheel of a street 
car, and the knee-joint opened. The fracture was exactly at the junction 
of the epiphysis and the shaft, and the periosteum of the latter was 
entirely stripped off for some distance, remaining attached to the epiphysis. 

The symptoms in the slighter cases described by Yogt, cases which 
might be classed as partial fractures or even as sprains, are few and in- 
definite, only the limited line of pain on pressure corresponding to the 
position of the conjugal cartilage, and the general symptoms of con- 
tusion or injury near the joint. When displacement is present the diag- 
nosis of fracture is not usually difficult, its position, the cartilaginous 
crepitus, and the age of the patient are the points upon which the differ- 
ential diagnosis must be based. If at the same time the epiphysis is 
dislocated the injury may be readily mistaken for a dislocation if the 
examination is not made thoroughly. 

The prognosis in the slighter cases is favorable, in the more severe 
ones it is made grave by the severity of the associated injuries. In 
addition there is the possibility that in case of recovery the subsequent 
growth of the limb may be checked by the premature ossification of the 



QZ VARIETIES OF FRACTURE. 

cartilage. This arrest of growth is rare, and even in some of the re- 
ported cases the exact nature of the original traumatism is in doubt, for 
there is reason to believe that premature ossification of the cartilage can 
be induced by a fracture of the shaft, and the cases are quite numerous 
in which it has followed inflammation of the bone. 

Bruns reported a case in which the shortening of the humerus in an 
adult following separation of the upper epiphysis at the age of two years 
was 14 centimetres. Bryant 1 speaks of one in which the shortening of 
the humerus amounted to five inches, and of another (loc. cit., p. 854) 
in which the shortening of the tibia amounted to an inch in two years in 
a child eight years old. Other cases are quoted by Vogt and Bruns. 

The principal reason of this non-interference with the growth in most 
cases appears to be in the frequent situation of the line of fracture in 
the layer of partly formed bone adjoining the cartilage. The osteogenic 
layer itself is not directly involved and its function is not interfered with. 
Another fact, which is a reason why the interference should not be noticed 
rather than why it should not occur, is that the injury is by far most 
frequent at an age when the growth of the skeleton is almost completed, 
and when the result of an arrest of growth, in the upper extremity at 
least, might easily pass unnoticed. In cases mentioned by Gurlt and 
Hamilton union failed and a false joint formed, and in one reported by 
Esmarch 2 a large abscess formed, and led to the removal of the epiphy- 
sis and a portion of the shaft (upper end of the humerus); the injury 
had been mistaken for a dislocation of the shoulder, and two attempts 
had been made to reduce it. 

The treatment requires no especial mention here. It is the same as 
that of other fractures in the same region, and will be described in con- 
nection with the special injuries of the different bones. 

(<?) Intra-articular Fractures. — The proximity of a fracture to a joint 
is always of importance on account of the possibility of the direct im- 
plication of the latter in the injury or in the subsequent inflammatory 
process to which the injury gives rise. The arthritis which may be 
thus set up adds greatly to the sufferings of the patient, complicates the 
treatment and endangers the integrity of the functions of the joint. 
The danger is greatest when the fracture extends directly through the 
bone into the joint, and to this variety is given the name intra-articular. 
The converse term extra-articular is applied to those fractures which are 
not thus complicated, but whose seat is sufficiently near an articulation 
to raise the question of the possible communication of the fracture with it. 

A fracture of the shaft of a bone may be made intra-articular by a 
fissure extending into the joint, as in the V-shaped fractures of the tibia 
and in some gunshot fractures, but much more commonly the main line of 
fracture involves a portion of the expanded articular extremity of a bone 
lying partly within the capsule, as in fractures of the condyles of the 
humerus or femur. Complete fractures of the patella and olecranon are 
necessarily intra-articular. 

A special signification of the term when applied to fractures of the 

> Surgery, 3d. Am. ed., p. 834. 

2 Arcliiv t'lir Klin. Cliirurgie, vol. xxi. 1878. 



COMPLETE FRACTURES. 



53 



Fig. 16. 




femur must be noted. An intra-articular fracture of the neck of the 
femur is one in which the line of fracture lies entirely within the cap- 
sule; when the fracture is entirely external to the attachment of the 
capsule it is called extra-articular, and when partly within and partly 
without it is called a mixed fracture. In like manner we speak also of 
an intra-articular fracture of the neck of the humerus, meaning one that 
lies entirely within the capsule. 

Intra-articular fractures owe their importance to their special ana- 
tomical conditions which retard the process of repair, introduce arthritic 
complications, make proper treatment more 
difficult, and affect the prognosis. These 
special conditions are the communication, 
usually free, between the seat of fracture and 
the cavity of the joint, the injury to the ar- 
ticular cartilage and the capsule, and in most 
cases the small size of the fragment which 
makes it difficult or impossible to apply an 
efficient retentive apparatus. 

The effect of communication betw r een the 
seat of fracture and the cavity of the joint is 
that the surface of the former is constantly 
bathed in the sero-sanguinolent liquid that 
fills the latter, the lymph which ought to aid 
in the formation of granulations to unite the 
broken pieces, is diluted and washed away, 
so that union, if not prevented entirely, is 
likely to be fibrous. The fibrous character 
of the union which is so frequent under these 

circumstances has been thought to be due to the specific action of the 
synovial liquid upon the granulations, but the opinion has not been sup- 
ported by satisfactory proof. The single case reported by Jarjavay and 
quoted by Follin 1 may have been merely a coincidence. It was that of 
a man 45 years old, who died of an intercurrent affection on the 42d 
day after he had fractured the external malleolus. The autopsy showed 
entire absence of inflammation in the joint or bone ; the fragments were 
in good position, and were united by a fibrous- band which presented no 
trace of cartilaginous or bony structure. Those who claim that the ab- 
sence of bony union in this case was clue to the contact of the synovia, 
overlook the possibility that it may have been a simple coincidence, and 
that fibrous union sometimes occurs where this agency is certainly not 
involved. Sometimes an osteitis is set up in the fragments which, when 
added to the pre-existing synovitis, is sufficient to cause necrosis of the 
articular cartilage and probably destroy the future usefulness of the joint. 

The injury to the other constituent parts of the joint excites therein 
an inflammatory process which is usually acute, and may end in suppu- 
ration ; in any case it is followed by a thickening and loss of pliability 
in the capsule and periarticular tissues, and possibly by the formation of 
intra-articular bands between the opposing surfaces of bone or capsule, 



Intra-articular fracture of the 
head of the tibia, with impaction 
aud separation of the upper frag- 
ments. 



1 Pathologie externe, vol. ii. p. 757. 



54 



VARIETIES OF FRACTURE 



which may permanently restrict the range of motion. An acute arthritis 
in a large joint is always a serious affection, full of danger to the limb, 
and even to the life of the patient. 

Displacement of the fragments after fracture of the articular end of a 
long bone, as, for example, of either condyle of the humerus or femur, 
is favored by the action of the attached muscles, and is difficult to oppose 
because the fragment is too small to be controlled by the dressing. 
When the fracture is not only intra-articular but also intercondyloid, 
that is, when both condyles are separated from the shaft and also from 
each other, this difficulty is much increased ; the two fragments separate 
laterally, and the other member of the joint is drawn up by the tonicity 
of the muscles into the interval between them. Consequently, when 
union has taken place the functions of the joint are found to be diminished, 
or entirely destroyed, by the change in the relations of the articular 



Fig. 17, 



Fig. IS. 





Intra-articular fracture of the lower end 
of the humerus, with exuberant cailus, 
especially in front. 



Intercondyloid fracture of the humerus 



surfaces to each other, or by overgrowth of the callus in the interval. 
In young people who have not yet reached their full stature, and whose 
bones are prone to excessive and irregular formation of callus, this is a 
frequent cause of crippling, especially at the elbow, where the callus 
may fill up the olecranon or the coronoid fossa and oppose an insur- 
mountable mechanical obstacle to the movements of flexion and exten- 
sion. These changes will be studied more fully in connection with the 
subject of repair of fractures. 

The diagnosis in the case of a simple fissure extending from the frac- 
ture to the joint can be based upon the nature of the main fracture, upon 
the fact that certain kinds are usually complicated by fissure, and upon 
the occurrence of inflammation within the joint ; in the other cases, 
where the fracture occupies the articular end of the bone, it is made by 
recognition of the size and shape of the fragment and of the deformity. 



MULTIPLE FRACTURES 



55 



It often happens that blood escapes so freely from the torn vessels that 
it fills up the cavity of the capsule, and by preventing palpation of the 
bony parts makes an exact diagnosis very difficult. 



3. Multiple Fractures. 

Under this term are included simultaneous fractures of two or more 
bones in different parts of the body, and two or more fractures of the 
same bone at different points. The latter variety passes by gradations in 
the size and number of the fragments into that known as comminuted 
fracture, which will therefore also be considered under this head. The 
simultaneous fracture of both bones of the forearm, or of the leg, is not 
called a multiple fracture, and Malgaigne also excludes from this class 
the fracture of two or more adjoining ribs. 

The simultaneous fracture of two or more bones may be produced by 
a great variety of causes, and its importance, so far at least as the life of 
the patient is concerned, depends largely upon the immediate cause of 
the injury. When this cause, as is so frequently the case, is found in 
the action upon the body of extreme violence, as in a fall from a great 
height, the explosion of a boiler or of a blast, the caving in of an em- 
bankment, or the fall of a heavy block of stone, it often involves such 
serious injury to other organs, or so much shock to the system, that 
death terminates the case promptly; or the local injury is so great that 
the surgeon is called upon, not to treat a fracture, but to perform an 
amputation. When, on the other hand, the fractures are caused by a 
moderate violence exerted only upon the limbs which are broken, the 
prognosis is not much more unfavorable than in similar single fractures. 
Dupuytren first called attention to the fact that while the danger of 
wounds and fractures is undoubtedly greater when they are numerous, 
yet it does not increase in direct proportion to their number ; on the 
contrary, when there are several fractures each one runs a milder course 
in general than if it were single. Malgaigne and V alette repeat and 
confirm this statement so far as it relates to simple fractures, and the 
former suggests as a possible explanation, that when the vital force is 
thus distributed among several points, it cannot excite as much reaction 
at each as it could do if confined to a single one. 

In Malgaigne's list of 2358 fractures there were 30 patients present- 
ing 67 fractures, counting those of both bones of the leg or forearm or 
of several ribs as one. They were distributed as follows : One patient 
having 4, six having 3, and the rest 2 apiece. 



Fractures 


of the leg .... 


26 


i . 


" thigh .... 


14 


a 


u arm .... 


7 


u 


" head . . . . 


7 


U 


" clavicle . . 


4 


u 


''- forearm 


3 


a 


" vertebral column . 


3 


Scattering 




3 



56 



VARIETIES OF FRACTURE. 



Fracture of a single bone at two separate points is an injury of rare 
occurrence. The fractures may occupy the shaft alone, or the shaft and 
one epiphysis (fig. 19), or both epiphyses (fig. 20). So far as known 
such fractures have been produced only by direct violence, usually a 



Fig. 19. 



Fig. 20. 





Multiple fractures of both, bones of the 1< 



Multiple fracture of the fibula, 



crushing force exerted by a large and heavy body. Sir Astley Cooper 1 
reported a case of double fracture of the shaft of the humerus in a man 
seventy-one years old by a fall against the edge of a curbstone. 

Multiple fractures characterized by communicating lines of fracture 
and the consequent production of several fragments of large size are 
much more common, and are found in the shafts and epiphyses of long 
bones and also in short bones. They may be produced by indirect as 
well as by direct violence, and in their simpler foruis are usually the re- 
sult either of the breaking off of some of the prominences of an oblique 
or dentate fracture, or of the splintering action exerted upon an epiphy- 
sis by the broken end of the shaft. These fragments exert an important 
influence upon the course and termination of the case ; if numerous, and 
if separated also more or less completely from the periosteum through 
which alone their nourishment can be assured, they may act as foreign 
bodies, excite suppuration, and finally be expelled, sometimes only after 
the lapse of several years. By becoming lodged between the principal 



Guy's Hosp. Reports, vol. iv. 1839. 



MULTIPLE FRACTURES. 57 

fragments of the shaft of a bone they may prevent complete reduction 
of the displacement, and render a certain amount of deformity or short- 
ening unavoidable ; and when formed by portions of the articular end of 
a bone they are almost certain to interfere seriously with the future use- 
fulness of the joint by modifying the relations of its opposing surfaces. 

Comminuted Fractures. — Strictly speaking, a comminuted fracture is 
one in which a portion of a bone is broken up into small fragments, and 
in that sense the term is now generally understood, although Dr. Hamil- 
ton 1 uses it as a synonym of multiple, without regard to the size of the 
pieces. That the classification is somewhat vague, and that the boun- 
dary-line between this variety and that of multiple fractures is uncer- 
tain, is the natural result of the innumerable gradations in size between 
the largest and the smallest fragments, and of *the frequent combination 
of widely different sizes in a single case, but fortunately this is without 
importance. This variety also includes impacted fractures and fractures 
with crushing, which are of frequent occurrence in the expanded ends of 
the long bones, especially in the old, and are usually accompanied by 
absolute loss or destruction of a considerable amount of the spongy 
tissue. 

Comminuted fractures present notable differences in the size and num- 
ber of the fragments and in their relations to each other and the sur- 
rounding soft parts. A bone may be broken into many fragments, and 
yet the relations of the pieces may be well preserved by the support 
given to them by the periosteum and adjoining tissues. This is especi- 
ally the case in the short bones and in the spongy portions of the long 
ones. On the other hand, the fragments may be so numerous and so 
thoroughly detached, and the surrounding muscles so crushed and torn, 
that the limb feels like a bag full of bones ; or one of the fragments may 
be driven into another and impacted among the pieces into which the 
latter is split. Under these last conditions the limb is shortened, but ab- 
normal mobility and crepitation may both be prevented by the firmness 
with which the fragments are wedged together. Permanent deformity 
is rendered inevitable by the separation of the fragments and the de- 
struction of a certain amount of the spongy tissue. 

When the bone has undergone the common senile change character- 
ized by rarefaction of its spongy tissue, interstitial atrophy, this impac- 
tion may take place without splitting, but with crushing and practical 
destruction or condensation of a portion of one or both fragments, and 
a similar effect is sometimes produced in the short bones without impac- 
tion ; the bone is simply crushed together or compressed. This is the 
so-called fracture ivith crushing, and, although most common in ad- 
vanced life, is frequently seen in the vertebrae without senile change. 
The meshes of the spongy tissue, which are filled with fat and bounded 
by thin lamellae of bone, are broken down and their contents squeezed out, 
so that an absolute and often considerable loss of substance results, which, 
if not made good by the formation of new bone, leads inevitably to a 
permanent deformity, or to a failure of union between the principal frag- 
ments. 

1 Fractures and Dislocations, 3d ed. p. 27. 



58 



VARIETIES OF FRACTURE. 



The cause of comminuted fractures of the shaft of long bones is 
usually direct violence, such as the passage across the limb of a loaded 



Fig. 21. 




Fig. 22. 




Comminuted fracture of the femur, with 
splitting of the condyles. 



Comminuted fracture of the neck of the femur. 



wagon or the fall of a heavy body ; in the spongy bones of the foot, or 
in the vertebrse, it is sometimes produced by a fall upon the feet from a 
height, and in the expanded ends of the long bones by either direct or 



Fig. 23. 



Fig. 24. 





Comminuted fracture of the lower end 
of the radius. Palmar aspect. 



Impacted fracture of the neck of the femur 
without splintering. Vertical section. 



indirect violence. On the other hand, a comminuted fracture of the 
neck of the humerus or femur can be produced in persons whose bones 
have undergone senile change by very slight causes, such as a misstep 



COMPOUND FRACTURES. 59 

or a fall upon the floor while walking. When the injury is caused by 
direct violence, the soft parts are usually involved to such an extent that 
the fracture is, or soon becomes, a compound one. In the treatment of 
compound comminuted fractures, only such fragments should be removed 
at the first dressing as are entirely loose in the wound or but very 
slightly attached. 

A positive diagnosis of comminution may sometimes be made by direct 
exploration of the seat of fracture through an accompanying wound, 
or by palpation of the fragments where the bone is subcutaneous. Under 
other conditions the surgeon must often be content with a " probable" 
diagnosis based upon the nature and mode of action of the causative vio- 
lence, upon the seat of the fracture, and upon the age of the patient. 

4. Compound Fractures. 

A compound fracture is one in which communication between the seat 
of fracture and the external air is established through a wound of the 
soft parts. The existence of this communication has an important influ- 
ence upon the prognosis, one that depends not upon the simple addition 
of another traumatism, or upon the greater violence that has caused the 
fracture, but upon the modification which the contact of the air produces in 
the process of repair and upon the train of serious complications which may 
result. The difference between simple and compound fractures is similar 
to that which exists between subcutaneous and open wounds ; in the 
former, recovery takes place in the great majority of cases speedily and 
without suppuration ; in the latter, suppuration is often inevitable, and 
the patient is exposed to all the complications to which it may give rise 
or for which it may furnish the opportunity. It is not the simple addi- 
tion of an external wound that introduces the element of danger, but it 
is the communication between the two and the consequent possibility of 
a change in the character of the reparative process at the seat of frac- 
ture, of irritation of the medullary and spongy tissue of the bone, of de- 
composition of the discharges, and of the absorption of the products of 
this decomposition which is specially favored by the presence of an open 
medullary canal, and by the difficulty of properly draining the irregular 
and deeply situated cavity. A coexistent wound of the soft parts which 
does not communicate with the fracture, even if in its immediate neigh- 
borhood, does not create the same danger, and does not entitle the frac- 
ture to be called compound ; the fracture remains a simple one and pur- 
sues the usual course, the wound usually having no more effect upon it 
than if it were at a distance, except in so far as it may interfere with 
the application of a splint. An additional element of danger arises from 
the usually greater causative violence, and lies in the greater probability 
of the coexistence of other complications, such as hemorrhage from a 
wounded vein or artery, rupture of a nerve, or communication of the 
fracture with a neighboring joint. 

It is impossible to make an exact statistical statement of the prognosis 
in compound fractures, for the reason, among others, that the results ob- 
tained in different hospitals vary widely. It is unquestionable that of 
late years, especially since the more general adoption of antiseptic treat- 



60 VARIETIES OF FRACTURE. 

ment and the greater care and attention given to obtaining thorough drain- 
age and maintaining cleanliness of the wounds which the discussion of 
that subject has produced, the results have been much improved. It 
seems hardly probable that the experience of Volkmann, who, previous to 
1873, lost by death three out of every four cases of compound fracture 
in his hospital service, will ever be repeated ; while, on the other hand, the 
most perfect treatment will not always obviate the necessity for amputa- 
tion or the risks of hemorrhage, shock, and delirium. As an evidence 
of what may be obtained by antiseptic treatment, I may quote Mr. Mac- 
Cormac's report 1 of sixteen successive cases of compound fractures, 2 of 
the femur, 3 of the upper extremity, and 11 of the tibia, thus treated, 
which furnished fourteen recoveries, one amputation, and one still under 
treatment for delayed union. Yolkmann, 2 in his address on Surgery be- 
fore the International Medical Congress in 1881, said he had treated 
antiseptically 135 successive compound fractures ; 133 recovered, 1 died 
of fat embolism, and 1 of delirium tremens. 

Compound fractures are most frequent in the lower extremity, and 
comprise, according to Gurlt, nearly 16 per cent, of all fractures of the 
limbs. Excluding fractures of the metacarpal and metatarsal bones and 
phalanges, they occur most frequently in both bones of the leg, 17.96 
per cent. ; then in both bones of the forearm, 11.68 per cent. ; then in the 
shaft of the femur, 7.05 per cent.; and then in the humerus, 6.66 per 
cent. They are most dangerous when the bone is deeply covered by the 
soft parts, least dangerous when it is subcutaneous. 

They are produced by both direct and indirect violence, but more 
frequently by the former than by the latter, and in that case are much 
more rarely accompanied by clean-cut wounds than by bruising and 
crushing of the soft parts. The communicating wound may be made 
from without inwards, or from within outwards ; in the former manner, 
when the violence is direct, by immediate division of the soft parts down 
to the bone, or by their subsequent sloughing in consequence of- the 
contusion they have received ; from within outwards when the end of 
one of the fragments is forced through the skin, or when, in the case of 
an intra-articular fracture with accompanying dislocation, the skin is 
broken by being stretched across one of the bony edges or prominences 
of the joint. In both these latter cases the bone projects through the 
opening in the skin, which is usually small enough to grasp it tightly. 

A fracture that is simple at first may be made compound by the 
sloughing of the skin over the projecting end of a fragment which can- 
not be properly reduced, or by the subsequent forcing of a fragment 
through the skin by the careless handling of those who first come to the 
patient's aid, or by his own act during delirium, or while still in igno- 
rance of the nature of the injury he has just received. Thus, Ambroise 
Pare, having had his leg broken by the kick of a horse, stepped quickly 
backward, and bringing his weight upon the broken limb forced the end 
of one of the fragments through the skin. The English surgeon, Pott, 
appreciated this danger so fully, that when he suffered the fracture at 

1 British Medical Journal, December 6, 1879, p. 907 

2 Lancet, August 13, 1881, p. 283. 



COMPOUND FRACTURES. 61 

the ankle which is now known by his name, he refused to allow him- 
self to be raised from the ground until a shutter had been brought upon 
which he could be carried. Gurlt 1 quotes three singular cases in which 
a piece of the projecting bone was broken off outside the body. In one 
of them the end of the humerus, broken by a fall from the mast, was 
forced half an inch into the planking of the deck, and a piece of the 
bone three inches long broken off"; in another a piece of one of the 
bones of the leg more than an inch long was broken off in the ground by 
contact with a stone ; and in the third a piece of the femur, two and 
three-quarter inches long and three-quarters of an inch thick, comprising 
half the thickness of shaft of the bone, was found in the patient's 
trousers after a fall from a height of twenty feet. All three cases re- 
covered, the last one with an angular displacement for which the patient 
underwent re-fracture at the hands of Langenbeck. 

When the bone projects, or can be seen through the wound, there is 
of course no difficulty in making the diagnosis. But it is not always so 
easy. The coexistence of a fracture with the recognized wound of 
the soft parts may be determined by the usual diagnostic methods, and 
then the question arises whether or not they communicate with each 
other. If the wound is large, ragged, and badly bruised, the finger or 
a probe may be cautiously introduced to feel for bare bone, but as a 
rule, such explorations are rather to be avoided. If the doubt cannot 
be otherwise cleared up it is better to consider the fracture a compound 
one, and treat it accordingly : if it proves not to be one, no harm is 
done ; while if it is compound, the only advantage of such an exploration 
would be the recognition of fragments that might need to be removed, a 
rather rare contingency. There are two other symptoms that have a 
certain diagnostic value, although they are not absolutely pathognomo- 
nic ; hemorrhage and the admixture with it of drops of fat continuing 
for several hours after the receipt of the injury. Hemorrhage from the 
soft tissues alone, unless arterial, does not usually last long, and if arte- 
rial can be recognized by its color, while the bleeding from a broken 
bone is always more profuse and long continued. Drops of fat seen in 
the blood immediately after the accident may have come from the sub 
cutaneous tissue, but those which appear after the lapse of several hours 
are much more likely to have come from the marrow of the bone. 

The treatment is the same as that of other fractures, with the addition 
of such measures as are rendered necessary by the wound of the soft 
parts, and it cannot be too strenuously urged that whenever there is any 
hope of obtaining primary union of the wound the attempt should be 
most carefully made, for if it succeeds the fracture becomes a simple 
one and pursues the usual course of such fractures. When the wound 
is small and clean-cut, especially if it has been made from within out- 
wards, the surrounding skin should be thoroughly washed with disinfect- 
ants after reduction has been made, and the limb has been placed in a 
retentive apparatus, and then the wound should be covered with a piece 
of gold-beater's skin, oil-silk, or thin rubber cloth fastened down on 
three sides by means of collodion. The fourth side, which should be 

1 Loc. cit., vol. i. p. 69. 



62 VARIETIES OF FRACTURE. 

the dependent one, is left open in order that the blood or discharges may 
drain away. Then compresses wet with carbolized water should be laid 
over the wound, and renewed as often as is necessary to prevent decom- 
position. By this means the wound can be watched as well as if it were 
exposed, and it is at the same time kept aseptic. This is a modification, 
introduced by Verneuil, 1 of the old method of treatment by occlusion, 
and renders it more certain as well as applicable to a larger number of 
cases. Even if the wound of the skin suppurates, primary union may 
take place in the deeper portions and serve the same important purpose 
of rendering the fracture simple instead of compound. 

If the soft parts are crushed or a joint largely opened, so that primary 
union is not to be hoped for, the fracture must be reduced, and the limb 
perfectly immobilized in an apparatus that will permit the wound to be 
properly dressed, and by a proper dressing is meant one that secures 
drainage and cleanliness. The full Lister method is to be highly recom- 
mended, but if it is not practicable the surgeon may still hope to obtain 
an equally good result by the free use of carbolic acid and close atten- 
tion to the wound. Prof. Markoe 2 has recently introduced a method 
which has given excellent results both in his hands and in those of others. 
He passes drainage-tubes through the wound and counter-openings made 
for the purpose, and injects a 2 J-per cent, solution of carbolic acid three 
or four times each day. He thinks the carbolic acid has a desirable 
topical effect upon the wounded tissues and favors healing in this man- 
ner as well as by preventing decomposition of the discharges. If the 
wound can be kept aseptic, the dangers of an unsuccessful attempt to 
save the limb are greatly diminished, and the patient is likely to reach 
the period when a secondary amputation or excision can be performed 
with a good prospect of success. By the use of antiseptic measures the 
surgeon may be often spared the necessity of deciding promptly upon 
an amputation, a decision which in doubtful cases is always the source 
of great anxiety, and, when not accepted by the patient, is liable to give 
rise to unjust and unfavorable comment if he is fortunate enough to 
escape with his limb and life. 

5. Gunshot Fractures. 

Gunshot fractures are a variety of compound fractures entitled to 
separate consideration, not merely by reason of the special nature of the 
violence that produces them, but also on account of their severity, their 
numerous complications, and their grave prognosis. In speaking of them 
as compound fractures the fact that in rare instances a spent ball or 
fragment of shell may cause a simple fracture is not overlooked, but 
these cases, although literally gunshot fractures by virtue of their cause, 
belong more properly to some of the other classes, and have but little 
in common with the much more grave ones that have a similar origin. 

Gunshot fractures may occur in any part of the skeleton, but those 
which involve the bones of the cranium or the trunk are generally asso- 
ciated with visceral lesions that are either promptly fatal or of such 

1 Memoires de Chirurgie, vol. ii. p. 271. 

2 Am. Journ. Med. Sciences, April, 1880. 



.GUNSHOT FRACTURES. 



63 



importance that the fracture itself becomes a matter of secondary con- 
sideration. The fracture, when it involves a long bone, may be either 
partial or complete ; in the former case large or small splinters are 



Fig. 25.1 



Fie. 26. 5 



Fig. 27. 1 





Partial fractvu 



Perforating gunshot frac- 
tures of the lower third of the 
humerus. 



'& ..:. 



Gunshot fracture 
of the humerus. 



broken off by a ball which strikes some project- 
ing portion of the bone, or glances from its shaft 
(fig. 25), or, more rarely, perforates it entirely 
without destroying its continuity. The complete frac- 
tures usually show an extreme degree of comminution, 
with long fissures running up and down the shaft 
(figs. 26, 27, 28). Usually the ball passes entirely 
through and beyond the bone, but sometimes fails to 
do so, and then lies loose in the adjoining tissues or impacted among 
the fragments (fig. 29). It occasionally happens in the smaller long 
bones, such as the fibula or the metacarpal bones, that the ball carries away 
a complete segment of the shaft, and thus creates a gap between the 
ends of the two main fragments that prevents their subsequent reunion. 
These are sometimes called " resection fractures." The gravity of shot 
fractures is due in great part to the degree of comminution, and to the 
fissures which insure the implication of the marrow in the traumatism to 
so considerable a distance ; the resulting osteo-myelitis increases the 
chances of pyaemia, and may lead to necrosis of the shaft of the bone 
and prolonged suppuration, which ends in amputation or in the death of 
the patient by exhaustion. 

The soft parts about the track of the ball are always so bruised and 
torn that sloughing and suppuration are inevitable ; and in civil practice, 
where the injury is much more commonly caused by the discharge of a 



1 From Med. and Sure. Hist, of the War of the Rebellion. 



64 



VARIETIES OF FRACTURE 



shotgun at short range than by a rifle ball, the destruction of tissue 
is exceptionally great. The proportion of serious associated injuries to 
the nerves and bloodvessels is greater than in compound fractures due to 
other causes, and they are especially liable to declare themselves by 



Fisr. 28. 



Fis. 29. 





Comminuted gunshot fracture of the head of the 
humerus. (U. S. Med. & Surg. Hist ) 



Gunshot fracture of the head of the humerus 
with impacted ball. (TJ. S. Med. & Surg, Hist.) 



secondary hemorrhages, the result of the sloughing of vessels that have 
been bruised but not immediately divided by the projectile, or that have 
ulcerated from prolonged contact with the ball, or a portion of clothing, 
or a fragment of bone. Another important and frequent complication is 
the implication of a joint by extension of a fissure to it, a complication 
which may be even more serious in its consequences than if the articular 
end of the bone were itself the seat of the principal injury, for it may 
lead to a secondary amputation, whereas under the other circumstances 
a useful limb may be preserved by resection of the joint, or a primary 
amputation be performed with a better prospect of success. 

The treatment and prognosis of gunshot fracture have been established 
mainly by the results of military surgery, and are not, perhaps, entirely 
applicable to cases occurring in civil practice, because the exigencies of 
the field of battle, the lack of opportunity for the care and precautions 
that should be immediately taken, the exposure often prolonged, the 
necessity for repeated transport over bad roads, the crowded hospitals, 
and the inability of the overworked surgeons and nurses to give each 
case the attentive personal care which is so desirable, combine to often 
force an amputation where, under more favorable circumstances, conser- 
vative treatment might be successful. The indications also are that the 
use of carbolized dressings will have the same effect in improving the 
prognosis with respect to both life and limb in this class of cases that it has 
had already in others. 1 The choice of treatment lies between amputation, 
excision of a joint, and pure conservative treatment in which the inter- 
ference is limited to removal of foreign bodies, provision for thorough 

1 See some remarkable cases of conservative treatment after gunshot wounds of 
joints in the Russo-Turkish War of 1878-79 in MacCormac's address, loc. cit., and 
in his Antiseptic Surgery, Smith, Elder & Co., 1880, p. 41. 



GUNSHOT FRACTURES. 65 

drainage, and giving exit to pus and splinters when they present them- 
selves. The question will be considered more in detail in the chapter 
on Treatment, and I shall limit myself here mainly to the restatement 
of some of the conclusions arrived at by Mr. Longmore, 1 Professor of 
Military Surgery at Netley, by Professor Langenbeck, 2 and Colonel 
Otis, the editor of the Medical and Surgical History of the War of the 
Rebellion. It must be borne in mind, however, that since these opinions 
were expressed the antiseptic methods of treatment have singularly di- 
minished the necessity for sacrificing limbs to save life. 

All authorities recognize the danger of operations undertaken during the 
intermediary period, that is, during the stage of inflammation and infiltra- 
tion of the soft parts, which begins from twenty-four to forty-eight hours 
after the receipt of the injury and lasts until the acute inflammatory pro- 
cesses have terminated in convalescence or in chronic suppuration. An 
operation therefore must be done at once, or postponed for three or more 
weeks. Colonel Otis gives the preference unhesitatingly to the primary 
operation, and so does Mr. Longmore in amputations, while Langenbeck 
recommends quite as strongly secondary excision of the shoulder and 
ankle joints, except in rare cases and primary excision of the elbow and 
possibly of the wrist. 

Excision is to be preferred to amputation after shot fracture of the 
upper articular extremity of the humerus, when the main vessels and 
nerves are uninjured ; and Langenbeck reports two cases to show that 
extensive laceration of the soft parts is not a contra-indication. For in- 
jury of the shaft of the humerus amputation in continuity when possible 
is always to be preferred to disarticulation, and the United States 
Reports show very positively that amputation in the lower third is much 
more fatal than amputation at a higher point, or even than disarticulation 
at the shoulder. 

At the elbow the danger of conservative treatment or delayed opera- 
tion lies in the facility with which suppuration spreads among the mus- 
cles of the forearm, and the disability of the hand which results from 
this, and the necessary evacuating incisions by reason of adhesions 
among the tendons. Moreover, conservative treatment, if successful, 
ends inevitably in ankylosis of the joint. If the vascular and nerve 
supply of the forearm is uninjured an attempt therefore should be made 
to save the limb by excision. 

Primary amputation of the forearm is condemned by Colonel Otis, 
"except in rare cases where the tissues are almost disorganized," and 
he expresses the most unqualified disapproval of the excision of portions 
of the shafts of these bones. The same w T riter says it is still uncertain 
whether or not excision of the wrist for injury is a proper operation, and 
Longmore expresses a doubt whether a satisfactory result is ever possible, 
but Langenbeck says, 3 that when the epiphyses of the radius and ulna 
and the carpal bones are shattered, especially if the ball has lodged in 
the wound, primary excision is certainly indicated ; while after simple 

1 Holmes's System of Surgery, vol. ii. 1870. 

2 Archiv fur Klin. Chirurg., vol. xvi. 1874. 

3 Loe. eit., p. 462. 



66 VARIETIES OF FRACTURE. 

perforation of the wrist, he would treat conservatively, and resect with- 
out delay whenever commencing infiltration of the forearm could not be 
checked by incisions. 

After shot fractures of the upper articular end of the femur, primary 
amputation has proved so fatal that it is now practically abandoned, and 
the choice lies between conservative treatment and excision. Both mea- 
sures have yielded a small proportion of successes. In those of the 
upper third, where the joint was not involved, the results of conservative 
treatment have been a little less bad than those of amputation. Shot 
fracture of the middle and lower thirds of the femur calls, as a rule, for 
primary amputation, for conservative treatment has furnished a conside- 
rably larger percentage of mortality. 

In fractures of the leg involving the knee-joint experience shows am- 
putation to be by far the safest treatment. Excision has given very bad 
results, which Langenbeck, however, thinks might be improved by the 
use of the immovable plaster splint. Conservative antiseptic treatment 
has recently furnished results which, if confirmed by further experience, 
will reverse this conclusion. Dr. Reyher, a surgeon in the Russian 
army operating in the Caucasus, reports eighteen cases of gunshot 
wound of the knee-joint treated conservatively and antiseptically, with 
only three deaths. 1 The limb was saved in fifteen cases, and with a 
movable joint. Fractures of the leg not involving either joint have done 
well under conservative treatment. Fractures of the ankle have been 
thought to require immediate amputation, and excision has been but re- 
cently introduced and rarely tried. Its results have not been very good, 
but Langenbeck nevertheless thinks that what he calls the " conservative 
expectant" treatment should be more generally employed, because the 
superficial position of the bone allows free incisions and ready extrac- 
tion of splinters, and the tendons do not need to be carefully preserved, 
since ankylosis, with the foot in a good position, should be the result 
sought for. Immobilization in a plaster splint is essential, with the foot 
at right angles to the leg, and without any deviation about its own lon- 
gitudinal axis. 

If conservative treatment of a gunshot fracture is determined upon, 
the limb must be immobilized as completely as possible, foreign bodies 
and detached splinters removed from the wound, and drainage secured 
by counter-openings if necessary. The weight of testimony is against 
interference with attached splinters, or the removal of the sharp ends of 
the principal fragments. 

1 Volkmann's Sammlung Klinischer Vortrage, Aug. 1878 ; quoted by MacCormac, 
loc. cit. p. 41. 



DISPLACEMENTS. 67 



CHAPTER III. 

DISPLACEMENTS. 

The relations of the two principal fragments produced by fracture of 
a bone may be altered in various ways, which Malgaigne classifies under 
six heads. This classification has been generally adopted, with the un- 
derstanding, however, that a fracture usually presents a combination of 
two or more of them, and that there is an additional group of cases in 
which the number of the fragments and the character of the displace- 
ment are such as to defy classification. Under exceptional circumstances, 
as when the periosteum is not torn, or when the broken bone is one of a 
pair, displacement may be entirely lacking. 

These six classes include displacements according to : — 

1st. The transverse axis of the bone, transverse or lateral displace- 
ment. 

2d. The long axis of the bone, angular displacement. 

3d. The circumference of the bone, rotatory displacement. 

4th. The length of the bone, overriding. 

5th. Penetration of one fragment by the other, impaction or crushing. 

6th. Direct longitudinal separation. 

1. Transverse or lateral displacement may take place forward, back- 
ward, or toward either side, and may be partial to any degree, or com- 
plete. In the latter case, that is, when the displacement equals the 
transverse diameter of the bone and the broken surfaces are no longer in 
contact with each other, the tonicity of the muscles draws the fragments 
past each other and adds overriding to the lateral displacement unless 
prevented by the presence of a collateral bone, as in the forearm or leg. 
Pure transverse displacement is rare, and practically may be said to 
occur only in transverse or dentate fractures. It is usually associated 
with longitudinal or angular displacement or both, as shown in figs. 
30 and 31. When the bone is subcutaneous and the fracture very re- 
cent the displacement may be recognized by the eye or the finger, but 
when the bone is covered by thick muscles or hidden by inflammatory 
swelling the displacement can only be inferred from the coexistence of 
another. Malgaigne mentions a case in which a large clot of blood two 
inches above the patella was mistaken by him for the projecting end of 
a broken femur. 

2. Angular displacement may vary in degree from a slight deviation, 
as in fig. 32, to a right angle, or even more, and may be associated 
with so complete and distant separation of the broken surfaces that the 
fragments form a T, as in figs. 34 and 35. It may sometimes be recog- 
nized by the eye, and it causes an amount of shortening which varies 



68 



DISPLACEMENTS 



directly with the degree of displacement, and the length of the shorter 
fragment. As has been before remarked, it is almost always found in 



Fig. 30. 




Fie. 31. 



Fig. 32. 




Transverse fracture of the femur. (Gurlt.) 



Angular displacement. 



partial fractures of the shaft and sometimes cannot be entirely reduced. 
After complete fracture it may be produced by the unopposed action of 



Fig. 33. 




Toothed fracture of the tibia. (Malgaigne.) 

the force of gravity upon the fragments or the limb, even after splints 
have been applied, or by the unbalanced contraction of certain muscles 
or groups of muscles. As a general rule, it can be corrected by perma- 
nent extension or lateral support, except when one of the fragments is so 
small or so deeply placed that it cannot be properly acted on by the 
apparatus. 



DISPLACEMENTS 



69 



3. In rotatory displacement one fragment, usually the lower, turns 
about its long axis, while the other fragment remains in position. Thus, 



Fi*. 34. 




Fracture of the clavicle. Union with extreme displacement. 
Fig. 35. 




for example, after fracture of the upper portion of the Fig. 36. 

tibia the foot and lower fragment may rotate outwards, 
while the knee remains in position, or, more rarely, as 
was pointed out by Gosselin, 1 the converse may occur, 
and the thigh rotate outwards, while the foot and lower 
fragment are held in position by the splints. This form 
of displacement is most frequently seen after fracture 
near the upper articular end of a long bone, when the 
unsupported weight of the limb tends to rotate it about 
its long axis, and it is, in fact, one of the diagnostic symp- 
toms of fracture at the neck of the femur. 

4. Overriding (fig. 37) is most common after oblique 
fracture of the shaft, and is produced by various causes, 
such as the continuation for a moment after the fracture 
of the force that has produced it, as in a fall upon the 
feet, the tonicity of the muscles, or the sliding down- 
wards of the body in the bed when the limb is fixed by 
a splint. It is to be recognized by the shortening which 
it causes, and is frequently associated with angular dis- 
placement (fig. 30). The most extreme examples are 
found after fracture near the end of a bone, where the 
shaft has split the epiphysis and passed between its 
fragments (fig. 38). 

5. Displacement by penetration or crushing has been 
already mentioned as the impacted variety of multiple fractures (p. 57). 
In short bones, that is, in those composed entirely of spongy tissue without 
a medullary canal, there is coincident crushing of both fragments at the 
seat of the fracture by which an actual loss of tissue is produced and the 
bone is shortened and bent (fig. 39). In the long bones it occurs only 
at the expanded, spongy ends, and is produced by the penetration of the 



Rotatory displace- 
ment after frac- 
ture of the neck 
of the femur. 



1 Clinique Chirurgicale, vol. i. p. 270. 



70 



DISPLACEMENTS. 



firmer and narrower fragments into the other, which is broader and more 
gy in structure. This penetration is made possible either by the 



SDOll 



Fig. 37. 



Fig. 38. 




Fracture of both bones of the leg, with overriding. 



Comminuted fracture of the 
femur, with splitting of the con- 
dyles. 



splitting of the penetrated fragment or by the crushing of its spongy 
tissue, as in the short bones. The accompanying figures represent these 



Fig. 




Fracture of the calcaneum, with crushing. 



two varieties. Usually it is the diaphysis which penetrates the epiphysis 
(fig. 40), but in fracture of the neck of the femur the latter usually 
penetrates the great trochanter (fig. 41), in accordance with the rule 
that the smaller, narrower fragment penetrates the broader one. Pene- 
tration without splitting occurs only when the spongy tissue has under- 



DISPLACEMENTS. 



71 



gone the senile atrophy or change characterized by enlargement of its 
meshes and thinning of its trabeculse. The penetration rarely takes 



Fi<r. 40. 



Fie. 41. 





Intra-avticular fracture of the head of 
the tibia, with impaction and separation 
of the upper fragments. 



Fracture of the neck of the femur, with 
crushing of the spongy tissue. Vertical 
section. 



place without a change in the direction of the axes of the fragments ; 
the resistance in the penetrated portion is greater on one side than 



Flo-. 42. 



43. 



44. 






Fracture of the neck of the humerus 
with impaction. (Malgaigne.) 



Fracture of the lower 
end of the radius. Angu- 
lar displacement of the 
lower fragment backward 
with impaction. (R. W. 
Smith.) 





Fracture of the fibula. 
Longitudinal separation. 



72 



DISPLACEMENTS. 



on the other, or the cortical shell of the penetrating one is thicker 
and firmer at one portion of its circumference than at another, so that 
the depth of the penetration varies and an angular displacement results ; 
or the same effect is produced when the direction of the fracturing force 
is not parallel to the long axis of the bone, as in some fractures of the 
lower end of the radius (figs. 42, 43). 

The exuberant callus found after consolidation of the fracture gives 
the appearance of a much deeper penetration than has actually taken 
place ; thus, in figure 43 the triangular mass of spongy tissue on one 
side of the shaft is not the penetrated epiphysis, as it seems to be, but 
is composed in part of callus that has formed above the line of fracture. 

When the impaction is in the general direction of the long axis of the 
bone, as at the upper end of the humerus or the lower end of the radius, 
the limb is shortened ; but when it is nearly at right angles, as at the 
neck of the femur, shortening may be absent or not appreciable ; crepi- 
tation and abnormal mobility are also usually lacking. 

6. Direct longitudinal separation is seen most frequently after frac- 
ture of the patella or of an apophysis to which a powerful muscle is 
attached, such as the olecranon or the coronoid process of the ulna. It 
is also seen after fracture of either malleolus when the foot has been 
dislocated towards the opposite side and has carried the fragment of the 
tibia or fibula with it (fig. 44). Gurlt 1 speaks also of the occasional 
production of this displacement after fracture of the shaft of the humerus 



Fis. 45. 




Fig. 46. 



Bony union of the patella. (Bryant.) 



by the unsupported weight of the forearm and lower frag- 
ment overcoming the contraction of the muscles which 
usually draw the fragments closer together with over- 
riding. 

This displacement is by far most frequent after trans- 
verse fracture of the patella, and is due there to the re- 
traction of the powerful quadriceps femoris which draws 
the upper fragment upward, sometimes to a distance of 
several inches. It can usually be .recognized without 
difficulty by palpation, which shows the existence of a 
groove or sulcus of varying width between the frag- 
ments. Figures 45 and 46 represent two fractures of 



'••m-f 



1 Loc. cit., vol. i. p. 108. 



DISPLACEMENTS 



73 



the patella in one of which bony union had taken place with moderate 
separation, and in the other fibrous union with wide separation. 

Among the irregular displacements, those which do not fall entirely 
within the above classification, may be mentioned rotation of one frag- 
ment about its transverse axis, as seen in some fractures of the neck 
of the humerus ; in extreme cases this rotation may bring the articu- 
lar surface into contact with the upper end of the lower fragment. 
Another is the crossing of the fragments in the form of an X (figs. 47 and 
48) ; a third is the interposition of a bone between two fractured ones, 
as in fig. 49, where the astragalus is represented as having been forced 



Fig. 48. 




^^ 



Fracture of the neck of the femur. 



Fracture of the clavicle. 



up between the tibia and fibula ; and a 
fourth includes many comminuted fractures, 
especially such as the common extra-cap- 
sular fracture of the neck of the femur with 
splitting of the great trochanter (fig. 50), 
in the separation of the condyles of the 
same bone (fig. 38). 

The character and degree of the displace- 
ment in any given case depend to a certain 
extent upon the direction and nature of the 
fracture. Thus, in a partial fracture the 
only displacement possible is an angular 
one, and in a dentate transverse fracture lateral displacement and over- 
riding are usually prevented by the interlocking of the bony points, 
while on the other hand, an oblique fracture greatly favors the simul- 
taneous occurrence of all these forms. 

The active causes of displacement are of two kinds : forces external 
to the body, and muscular action, voluntary or involuntary. The first 
comprises the immediate action of the fracturing force and the prolonged 
action of gravity upon either fragment or the entire limb during the 
period of repair. Usually these displacements may be overcome, .and 
their recurrence prevented, whenever the fragments are sufficiently large 
to be controlled by suitable splints, and when there is not much commi- 
nution or crushing. The displacements in impacted fractures and in 
most compound ones where the end of the bone projects through the 
skin, are produced at the moment of the fracture by the fracturing force, 
while most rotatory and many angular displacements are due to the 
gradual sagging of the limb or of a fragment. One of the most common 
examples is the outward rotation of the foot after fracture of the neck of 
the femur. 



<4 DISPLACEMENTS. 

Voluntary muscular action is a cause of displacement, either at the 
moment when the fracture is received and the patient is in ignorance of 
the character of the injury, or subsequently, when he is delirious or 
insubordinate. Involuntary muscular action is a cause that is always 
ready to take advantage of an opportunity and produce overriding or 



Fig. 49. 



Fig. 50. 





Fracture of tibia and fibula, with penetration of 
the astragalus between the fragments. 




Comminuted fracture of the neck of the femur. 



angular displacement. The pain of the fracture, and the irritation of the 
soft parts by the broken ends of the bones stimulate the muscles to 
steady permanent contraction, or excite twitchings and spasms which 
aggravate the pain and deformity. The traction of these muscles upon 
fragments which have lost their natural support either changes the re- 
lations of their axes or draws them past each other and shortens the limb. 
It is impossible to predict the direction and extent of the displace- 
ment by consideration of the muscles attached to the fragments. Too 
many other factors are involved, and experience has shown that fractures 
at any point may present displacements differing essentially from each 
other in different cases. At the same time, the effects of the contrac- 
tility of the muscles are not entirely casual and irregular ; the tendency 
to shortening of the limb by the combined action of all its muscles 
always exists in every case not complicated by paralysis, as does also a 
similar tendency to exaggeration of certain displacements produced by 
the fracturing cause and accompanied by free rupture of the periosteum 
and other soft parts. Malgaigne mentions a case of fracture of the neck 
of the humerus, in which the upper fragment was drawn into a position of 
extreme abduction by the supra-spinatus muscle after the lower fragment 
had been displaced far into the axilla. Lacroix 1 showed that, as a 

1 Annales de la Chirurgie Fran9ai.se et etrangere, 1844, vol. x. p. 257; quoted by 
Grurlt. 



DISPLACEMENTS. 75 

general, although not universal, rule, the displacements of the bones of 
the extremities formed angles which corresponded to the normal curves 
of these bones, which latter correspond in turn to, and are apparently 
due to the action of, certain groups of muscles. The influence of the 
muscles in most displacements by direct longitudinal separation, as after 
fracture of the patella, is, of course, beyond dispute. 



76 ETIOLOGY OF FRACTURES. 



CHAPTER IV. 

ETIOLOGY OF FRACTURES. 

The causes of fracture may be grouped under two heads : A. The 
predisposing causes, and B. The immediate or determining causes. 

A. The predisposing causes are also of two kinds: the normal or 
physiological, and the pathological. 

The normal or physiological causes are those which have their origin 
in the form, texture, and functions of the different bones, modified as 
they are by the changes incident to the advancing age of the individual. 
The statistics given at the beginning of this volume show how much more 
frequently the long bones are broken than the short ones ; and the rea- 
sons for this difference are not obscure. The liability of a bone to frac- 
ture depends upon its power of resistance, its exposure to violence, and 
the opportunity which it furnishes for the more or less advantageous 
action of this violence. The shaft of a long bone is composed of a hollow 
cylinder of very firm texture, an arrangement that gives the maximum 
of resistance against lateral flexion and breakage with the minimum of 
weight. Its principal exposure is to indirect violence, to flexion or tor- 
sion, which although applied through the ends of the bone, exerts its 
greatest fracturing force upon the shaft, as a stick is broken by bend- 
ing it. 

The short bones and the expanded extremities of the long ones have 
a different structure corresponding to their different functions and expo- 
sure. The violence which they receive is direct, their surfaces of contact 
therefore are large, and their texture uniform so as to provide for a ready 
transmission and division of the impinging force. Their shortness, both 
actual and relative, as compared with their thickness, protects them almost 
entirely from the action of indirect violence, and their relation to the 
shafts of the long bones is such that the direct violence which they re- 
ceive is transmitted into indirect violence exerted upon the latter. Thus 
in a fall from a height upon the feet the force is received upon the 
sole of the foot ; if the limbs and back are straight and rigid, it is 
transmitted directly through them and causes fracture by direct impact 
either at the ankle, or at the base of the skull, or at an intermediate 
point, but if the legs are bent and the muscles tense, the bones of 
the leg and thigh constitute, practically, a single curved bone with 
its maximum of curvature near the centre just above the knee, and 
that then becomes the point at which the fracturing strain is greatest. 
Figure 51 represents the relations of the bones of the leg and thigh 
when the knee is flexed, and the dotted lines show the direction in which 
the force is transmitted. The fracturing effort is greatest at the point 



ETIOLOGY OF FRACTURES, 



77 



where these lines cross, the point of maximum convexity in the lower 
third of the femur, and an additional demonstration of its character is 
found in the frequent projection of the lower end of the upper fragment 
through the skin of the anterior aspect of the thigh. The lateral and 
crucial ligaments, the tendon of the quadriceps femoris in front, and 



Fig. 51. 



52, 





attachments of the gastrocnemii behind, fix the condyles of the femur 
and the head of the tibia so firmly together that they form practically 
a continuous bone, and, as all experience shows, fracture above or below 
the joint is very much more frequent than dislocation. So far as fracture 
is concerned, therefore, the two bones are the same as a single bone 
having the shape represented in fig. 52. In like manner a fall upon the 
palm of the hand may fracture the humerus in its lower third. 

We find in the normal curves of the bones an indication of the means 
by which nature seeks to protect the skeleton from the effects of direct 
violence and which find their fullest development in flexion of the limbs 
and rigidity of the muscles. Every effort is made to distribute the vio- 
lence and to take it up by the elasticity of the different segments, in a 
word, to make it indirect instead of direct, to avoid shock even at the 
risk of fracture. The instinct which leads a falling man to stiffen his 
muscles is calculated to protect his viscera at the expense of his limbs. 
The proverbial immunity against fracture possessed by drunkards is cor- 
roborative of this view. 1 The additional factor of a direct strain upon 

1 Two cases were recently brought into my wards at Bellevue Hospital which, illus- 
trate this fact strikingly. One had fallen while intoxicated, from a fourth-story win- 
dow, and sustained no injury except contusions ; the other had fallen while asleep 



78 ETIOLOGY OF FRACTURES. 

the bone, by the contraction of the attached muscles will be discussed 
when we come to consider the direct influence of muscular action in the 
production of fractures. 

The position and functions of the extremities, especially the forearm 
and leg, also expose them to fracture to a degree far exceeding that of 
the bones of the trunk ; they are, as it were, outlying members, which 
are the first to receive the shock in a fall, they are often interposed to 
protect the head or body, they come into close relations with machinery, 
and are more frequently caught by falling bodies or moving wagons. 

The greater relative frequency of fracture in people over fifty-five or 
sixty years of age has been already mentioned. The cause was long 
supposed to lie in the presence of lime-salts in the bones of old people in 
larger proportion than in those of the young, but more recent investiga- 
tions have shown that the assumption upon which this explanation is 
based is incorrect. The proportions of organic and inorganic matter in 
the bone tissue itself do not change as supposed, and the real cause of 
the greater brittleness in advanced life is the actual diminution which 
then takes place in the amount of the bone substance. The external 
dimensions remain unchanged, but all the cavities increase in size by 
absorption of their walls, and become filled with fat so that the bone will 
almost float in water. The cylindrical shell of the shaft is so thinned 
in extreme cases that a very slight force is sufficient to break it, and the 
spongy tissue is similarly weakened by the disappearance of many of its 
trabecule, and the consequent enlargement of its meshes. This change 
is known as senile or interstitial atrophy, and is always present to a 
greater or less degree in advanced life. It is this weakening, this in- 
ability to withstand direct violence, that explains the especial frequency 
of certain fractures — notably those of the neck of the femur and impac- 
tion at the upper end of the humerus, or at the lower end of the radius. 
A stumble or misstep is often sufficient to fracture the neck of the femur 
in an old person, as is also a slight fall upon the knee or the great 
trochanter. 

In young children, whose epiphyses are almost entirely cartilaginous, 
the elasticity of this tissue is thought by Gurlt to be a protection against 
fracture of the shaft by indirect violence, but fractures are by no means 
so rare among them as to require such a purely hypothetical explanation 
of their rarity. They present the usual varieties of fracture, with a 
relative predominance of the incomplete or partial ones, and, as a rule, 
with much less displacement than is found in later life. This last fact 
is to be explained, in part at least, by the greater thickness of the 
periosteum. 

While atrophy is usually so moderate in degree and so widespread in 
its distribution, when it presents itself as a senile change, that it may be 
considered with propriety among the normal or physiological predispo- 
sitions to fracture, yet when it appears prematurely, or reaches an ex- 

from the roof of a four-story house and received a severe injury of the hack and a 
contusion of the foot, but had broken no bones except possibly one of the vertebrae. 
The former recovered promptly, the latter died of septicaemia originating in gan- 
grenous emphysema of the bruised foot, a dissection of which showed the absence of 
fracture. 



ETIOLOGY OF FRACTURES. 79 

treme degree, it is the result of something more than the usual senile 
wasting, and must be classed as pathological, together with other 
atrophies which show similar gross pathological changes, but whose 
nature and causes are far from being thoroughly understood. In the 
same connection may be mentioned cases of inherited congenital and 
developed liability to fracture, in which, as direct examination of the 
bones was not made, there is no knowledge of the accompanying 
anatomical conditions. Of the inherited liability Gurlt gives three ex- 
amples, extending in one case o\ r er four generations, in the others over 
three each. The following is a condensed report of one case : 1 — 

First Generation. — A woman had suffered five fractures of the left 
and one of the right thigh, caused by slight violence, and preceded in 
the last case by severe pain in the limb. Pier brother broke one thigh 
twice, the other nine times, the arm twice, and dislocated his hip once — 
all before he was thirteen years old. 

Second .Generation.— The son of the woman had fourteen fractures 
before he reached the same age (thirteen years). The first was a frac- 
ture of the femur caused by a fall from a step six inches high, and united 
in five weeks ; four months later the forearm was broken by a fall from 
a chair ; after another four months, fracture of the ulna by a wrench of 
the arm, united in three weeks ; again, four months later, fracture of 
the humerus, radius, and tibia on the right side, by a fall down two steps, 
about eleven inches ; all united in less than four weeks. Afterwards six 
fractures of different bones. 

He gives also three cases of a congenital but not inherited disposition 
to frequent fracture in the children of a family. In the first case three 
brothers were affected. The eldest suffered only one fracture, that of 
his right thigh, when he was three years old; the second brother had 
four, and the third had nine fractures between their second and nine- 
teenth years. With two exceptions the fractures were caused by 
moderate external violence ; they all united in four or five weeks, and 
caused deformity in only two cases. The liability disappeared as the 
patients advanced in years. 

In the second reported case a healthy but rather delicate girl suffered 
thirty-one fractures between the ages of three and fourteen years ; the 
right thigh seven times, the left once ; the right leg nine times, the left 
once ; the right arm four times, the left three times ; and the left fore- 
arm once. They all united rapidly and easily. Her sister, six years 
old, had suffered nine fractures, the first at the age of eight months. No 
similar predisposition existed in the parents, nor in the two brothers and 
a third sister. 

Gurlt admits his inability to find a sufficient explanation of the dispo- 
sition manifested in these cases, for neither parents nor children presented 
any recognizable cachexia or defective structure of the bones ; he places 
it, therefore, with that other obscure tendency, the hemorrhagic diathesis, 
among the problems whose solution requires many more detailed obser- 
vations. 

1 Gibson, Institutes and Practice of Surgery, 7th ed., 1845, vol. i. p. 237; quoted 
by Gurlt. 



80 ETIOLOGY OF FRACTURES. 

The cases in which individuals have developed in early 'or middle life a 
noticeable fragility of the bones without known cause are not very rare. 
Gurlt has collected seventeen such, characterized not only by the re- 
markable facility with which the fractures were produced, but also by an 
exceptionally rapid and easy recovery. He is unwilling to believe that 
in them, or in the preceding cases, the fragility was due to atrophy of 
the bone, because the majority of the individuals were reasonably well 
and strong, and did not show signs of that atrophy of the soft parts which 
has always accompanied atrophy of bone in cases where the latter con- 
dition has been verified by examination. 

The pathological condition known as general atrophy or rarefaction of 
the bone, or osteoporosis, and which has been referred 'to as senile 
atrophy, may appear prematurely, or may have its origin in other causes 
than senility — such as paralysis, locomotor ataxy, or osteomalacia. It 
is worthy of note, that in not a small proportion of the cases (excluding 
the ordinary fractures of the neck of the femur) union takes place easily 
and rather promptly. In most of the cases that furnish autopsies the 
bones are found softened and reduced to a shell by absorption from the 
inside, and in some of the cases suppuration has taken place at the frac- 
ture, and death has followed with symptoms of purulent absorption. 
The following cases, quoted from Gurlt, represent the different varieties. 

A woman, seventy-two years old, had both thighs broken by kneeling 
in church, and the humerus by the efforts of the bystanders to lift her 
up. Another broke her collar-bone by putting her arm about the nurse's 
neck, and trying to turn herself in bed. 

A weakly boy, with healthy parents, brothers, and sisters, began at 
eight months to suffer with boils (or cold abscesses) followed by exten- 
sive ulcerations, probably lupus, at the nose and ears. He had then six 
different fractures, which suppurated and caused his death at the age of 
2J years. The fractures involved the humerus, femur, both bones of 
the leg and forearm, and had not united. The bones were small, unu- 
sually spongy near the fractures, and could be easily cut with a knife, 
but were hard and rigid. The viscera were healthy. 

A woman, forty-five years old, the mother of two children, suffered a 
great deal of pain in her bones after the birth of the second child, and 
became so helpless that she could not get into or out of bed without aid. 
She broke both thighs below T the trochanters by stumbling against the 
bed-post in one case, and by turning in bed in the other. Both united 
with marked angular displacement, and at the autopsy the bones of the 
thigh and pelvis were found to be so light that they floated in water and 
could be crushed by pressure with the finger. The cortical substance of 
the femur was as thin as an egg-shell, the medullary canal enlarged, 
traversed here and there by delicate plates of bone, and filled with a 
grumous, semi-fluid mixture of blood and marrow. 

A woman, twenty five years old, began to suffer pain in all her limbs, 
especially the thighs, became bedridden, and died four days after she 
had broken her left thigh by turning in bed. The bones were of normal 
size, lighter than usual, and could be easily broken, with comminution 
and escape of much blood. The periosteum was loosely adherent, the 
bones dark red and full of blood ; the cortical layer of the femur was 



ETIOLOGY OF FRACTURES. 81 

only one line in thickness, and the canal was filled with a thick, dark 
red marrow. The neck of each femur was completely absorbed. 

A man, fifty-six years old, bedridden for many years, had both thighs 
broken while being turned in bed. Firm union followed. After death 
the bones were found atrophied and softened. 

Saviard saw in 1690 at the Hotel Dieu, in Paris, a woman about thirty 
years old who had suffered for four months with severe pains throughout 
the body, increased by movements and without fever. Three months 
later she had become bedridden, and her bones had grown so friable that 
most of them were broken, and she could not be moved without causing 
a new fracture. She lived ten months in this condition, and the autopsy 
showed fractures of almost every bone in the body. Their structure was 
so delicate that they could not be pressed between the fingers without 
breaking into small pieces ; the marrow was red, the muscles pale, the 
joints and cartilages unchanged. 

A waman, fifty-nine years old, with complaint of wandering pains, 
oedema, albuminous urine, fibrinous casts. Pains in the spinal column 
with gradual curvature ; pain in the first and second sterno- costal joints 
with swelling; fracture of the right clavicle near the sternal end without 
known cause ; lime salts abundant in the urine ; union of the fracture 
in twenty-three days. Three months afterwards, while turning in bed, 
fracture of the left clavicle at the corresponding point ; two days later 
fracture of the right femur three inches above the condyles by sitting up 
in bed and allowing the legs to hang over the side. Death six days 
afterwards. All the bones showed atrophy of the cortical layer and 
enlargement of the meshes of the spongy portion ; complete firm union 
of the left (?) clavicle (fig. 53) ; the ribs all bent and showing twelve 

Fi£. 53. 




United fracture of the clavicle. Osteomalacia. 

to fourteen fractures united with exuberant callus, but so friable that 
they could be broken by pressure between two fingers ; the vertebrae 
were as soft as gelatine, the pelvis normal in shape. 

Benjamin Bell 1 reports a case where only one bone was affected, and 
in which the pathological changes were different. He gives no intimation 
of the cause. "A gentleman at the middle period of life who fractured 
his humerus in unscrewing a music-stool. The fracture was comminuted 
and did not unite. Several months afterwards the arm was amputated 
by my father, Mr. George Bell, at the shoulder-joint. On examining 
the limb the muscles surrounding the fractured bone were found to be 
in a pulpy state, A quantity of partly fluid and partly coagulated blood 

1 Diseases of the Bones, 1828, p. 72. 



82 ETIOLOGY OF FRACTURES. 

enveloped the bone, which was fractured near its centre. Several frag- 
ments of bone, varying from one to three inches in length, lay imbedded 
in the blood. No attempt at the adhesive or reparative inflammation 
seemed to have been made. The bone was almost friable, and its outer 
surface, from the neck of the humerus to the condyles, was perforated 
by innumerable small, irregular-shaped holes, giving to the bone, when 
macerated, a true reticulated appearance ; and this peculiar reticulated 
appearance was also observable in the osseous plates of the cancelli." 

In the following case, that came under my care in 1880, the bone 
appears to have been weakened by a blow and a wound of the soft parts 
received about five weeks before. The patient was a healthy man, thirty- 
five years old, who was admitted to the Presbyterian Hospital with a 
lacerated wound across the front of the middle third of the left leg, 
caused by the fall of a stone. The wound healed in three weeks and 
he left the hospital. A fortnight later, Nov. 4, 1880, he returned with 
a compound fracture at the scar, caused by stepping down from a win- 
dow-sill to the ground, a distance of two feet. He had had no pain in 
the leg previously. The bone could be seen plainly and was rarefied 
and soft ; the fracture seemed to be transverse, and with but slight dis- 
placement. Recovery followed promptty . 

A similar friability is also found in some cases of old unreduced dis- 
location, due, it is supposed, to lack of use. This fact should always 
be borne in mind when an attempt is made to correct such a condition. 
Malgaigne thinks the danger of fracture exists only when the bone has 
been the seat of dull pain, and attributes it to a local inflammation ; but 
this opinion is hardly in harmony with all the reported facts. Prof. 
Markoe 1 reports a case of dislocation of the hip of seven weeks' standing, 
in which he fractured the femur while attempting reduction without 
apparatus and employing only a " slight amount of force." He repeats 
the same warning that the greatest care must be taken " in using bones 
which have long been disused, as levers in reducing displacements." 

Disease of the Nerve-centres. — In 1842 Davey called attention to the 
facility with which fracture sometimes occurred in lunatics, especially in 
those who were also paralytic, and the observation has been abundantly 
confirmed, Burns (vide infra) having collected more than sixty reported 
cases. Weir Mitchell 2 was the first to call attention to the frequency of 
fracture in those affected with locomotor ataxy, and suggested that the 
cause might lie in an impairment of the nutrition, and consequently of 
the strength, of the bone dependent upon the disease of the cord. 
Shortly afterwards Charcot 3 published a remarkable case of multiple 
" spontaneous" fractures and dislocations in an ataxic woman, and very 
recently Burns 4 has published a paper upon the subject based upon thirty 
cases reported within a few years. He finds that the fractures are 
usually multiple, from two to six in number, and are most common in the 
lower extremity, especially in the femur; the frequency is equal in the 
different bones of the upper extremity — clavicle, humerus, and forearm. 

1 Diseases of the Bones, p. 18. 

2 Am. Journal Med. Sci., July. 1873, p. 113. 

3 Archives de Phvsiologie, 1874, p. 166. 

4 Berliner Klin. Woclienschrift, 1882, p. 164. 



ETIOLOGY OF FRACTURES. 83 

Repair takes place in the usual time or in less, and the callus is some- 
times exuberant. 

The accident seems to occur more frequently in the earlier than in the 
later stages of the nervous disease, and its predisposing cause is a rare- 
faction of the bone marked by great absorption of the compact tissue, 
increase of fat, and loss of inorganic matter. It is not improbable that 
in some of the cases reported by the older writers and quoted above, 
especially in those in which pain is mentioned as a preliminary symptom, 
the patients were ataxic. 

Rachitis. — Friability due to rachitis is found only in childhood, for 
the disease is one which involves the bones only during their period of 
growth, and consists essentially in the prolongation and exaggeration of 
the embryonal or developmental condition of the shaft. The layer of 
tissue known as chondroid (Broca), or spongoid (Gue'rin), by means of 
which a bone grows in length, and which is intermediate between the 
shaft and the epiphysis of a growing bone, and is normally only a line 
or two in thickness, becomes in a rachitic bone very much thicker and 
continuous with a thick subperiosteal layer of similar tissue covering the 
entire shaft. The cylindrical shell of the shaft presents, instead of a 
solid, uniform, bony wall, a series of alternating layers of fully formed 
bone and the above-mentioned spongoid tissue, or there may be a thin 
compact shell adjoining the medullary canal and covered externally by 
a thick layer of this softer, incomplete, or embryonal bone. The disease 
is common among children of the poorer class, and those affected by it 
furnish, according to Guersant, about one-third of all fractures at that age. 

The spongoid tissue is composed of modified cartilage infiltrated with 
an abundance of lime-salts, and containing only a little real bone ar- 
ranged in irregular lamellae or patches ; it is more soft and friable than 
normal bone, more easily crushed or broken, and the most frequent form 
is the partial or incomplete fracture, impaction, with the fracture on the 
concave size of the bend. As the age of the individual increases, the 
bones acquire the normal structure, and their solidity is then as great as 
or even greater than it is under ordinary circumstances, because of their 
increased thickness. There is no lack of examples of rachitic fractures in 
foreign records, but the affection seems to be much rarer here. Mal- 
gaigne saw a rachitic child that had suffered four fractures (one of the 
humerus, three of the femur), between the ages of six and ten years, and 
quotes another from Jacquemille of six fractures (arms and thighs) between 
the ages of twelve and thirty-two years. In this latter patient apparently 
the rachitis had persisted much longer than usual. In the Dupuytren Mu- 
seum at Paris is the skeleton of a rachitic child, six or seven years old, 
showing twelve fractures. Lonsdale has reported one with twenty-two 
fractures, and in the London Medical Gazette (1833) is the account of 
another with thirty-one. Esquirol's famous case, mentioned in most 
works upon fractures, was a rachitic woman whose skeleton showed 
more than two hundred fractures, all more or less well united. 1 

Union takes place rather more slowly than in normal bone, and some- 
times fails entirely. The callus is usually large, but as it is composed 

1 Malgaigne. Fractures et Luxations, vol. i. p. 20. 



84 



ETHOLOGY OF FRACTUKES 




United fracture of rachitic 
femur. (Gurlt.) 



54 - of the same soft embryonal tissue whose excess is 

the pathological feature of the disease it is lacking 
in firmness. Fig. 54 shows how the medullary 
canal may be obliterated even in incomplete frac- 
ture, by the bending in of one of its sides, and also 
how the callus tends to straighten the outline of the 
bone by filling up the hollow of the angular dis- 
placement. 

Syphilis, Mercurialism, and "Rheumatism." — 
Syphilis affects the organism in so many and so 
varied forms, and causes such serious bone lesions 
in its later stages, that it is not strange that both 
physicians and patients have been inclined to attri- 
bute to it fractures produced by slight causes when- 
ever the patient was or had been affected by it. 
And in like manner those who saw in mercury the 
cause of the bone lesions of syphilis attributed the 
fractures to the use of that drug. 

When we remember what multitudes of people 
have contracted syphilis, how numerous those in 
whom it has caused grave lesions of the bones, and 
on the other hand how few are the cases in which 
it can even be suspected as a predisposing cause of 
fracture, it is evident that it has but little, if any, 
influence in this direction ; and an examination of the alleged cases shows 
very frequently a coexistent constitutional weakness or a cachexia not 
always to be attributed to the specific disease, which creates a close re- 
semblance between these cases and those in which the friability of the 
bone is due to a premature or exaggerated senile atrophy. The patho- 
logical anatomy of syphilis, too, does not show any morbid change pro- 
duced in bones by this disease which would markedly increase their 
friability, although there are some specimens of hyperostosis, of general 
enlargement of the shaft of a long bone, accompanied by such a rarefac- 
tion of the tissue that the strength of the bone is lessened, notwithstand- 
ing its enlargement. 1 have one such specimen in which the lower third 
of the femur is nearly doubled in diameter, while its wall is much thinned 
and abnormally porous. It is of course possible that this rarefaction 
may exist without hyperostosis or actual increase in size, and the strength 
of the bone be notably diminished thereby, but there is no proof of it, 
if we except the caries sicca of the cranial bones, a process marked by 
absorption of the bony tissue about the minute canals and under the 
periosteum, and consequent production of depressions on the surface or 
of perforations, some of which may extend entirely through the bone. 1 

In only two of the fifteen cases collected by Gurlt 2 in which fractures 
were produced by slight causes in syphilitic individuals were the bones 
examined ; in one of them after death, in the other incidentally to an 
operation for pseudarthrosis. Of the former it is stated only that the 



1 Compare Keyes, Venereal Diseases, 1880, p. 

2 Loc cit., p. 179. 



186. 



ETIOLOGY OF FRACTURES. 85 

bones were very friable ; of the latter it is said the pieces removed were 
soft and friable, and the medullary canal enlarged with notable thinning 
of its wall and a great excess of fat. In one case the humerus was 
broken two or three times and the clavicle twice, in the other the femur 
once by slight causes ; both patients were of delicate constitution, and 
one of them died,' apparently of phthisis, at the age of 27. They can- 
not be said to prove anything in this connection. 

It seems not improbable, on general grounds, that syphilitic pain in 
the bones may be the result of pressure within the Haversian canals or 
under the periosteum, and that this pressure if not relieved may result, 
as it does under other circumstances, in an enlargement of the affected 
canals by absorption of their walls, in other w T ords, in rarefaction of the 
bone and consequent diminution of its strength, just as in general atro- 
phy. Gurlt's fifteen cases include five in which the fracture was pre- 
ceded by severe pain, more or less prolonged, in the broken bone, and 
these might be considered as demonstrative of the influence of syphilis 
did we not possess other similar cases in which the syphilitic complica- 
tion does not exist. Malgaigne, 1 indeed, speaks of local inflammation of 
the bone as a frequent and too much neglected predisposing cause of 
fracture, adding : "I give this name, conjecturally, to an affection which 
generally manifests itself by dull pains attributed by the patient to some 
contusion or to rheumatism, rarely sufficient to cause a general reaction, 
and attracting but little attention until some slight cause produces frac- 
ture at the point it occupies." There is a striking similarity between 
the cases he cites in this direction and Gurlt's syphilitic cases. 

"Rheumatic" Cases. — A carpenter's apprentice suffered for a month 
with rather severe rheumatic pains in the left arm, and then broke it by 
pressing firmly upon the handle of a centre-bit, which he was turning 
with his right hand. 

A laborer broke his right arm by throwing a stone. He had always 
been healthy, but during the preceding month he had been suffering 
from pain in this arm which had increased to such a degree that he had 
stopped work. 

A strong well-built youth of 20 years broke his femur by a fall upon 
the ground while walking ; for a few weeks previous to the accident the 
limb had been the seat of pains supposed to be rheumatic. 

Syphilitic Cases. — A woman, 40 years old, had pain at night for a 
year in the middle of the arm, and then broke it at the affected point, 
without violence. On examination a perforating ulcer was found on her 
soft palate; the fracture healed in seven weeks under anti-syphilitic 
treatment, and a year later she presented herself with nodes on the left 
femur. 

A soldier suffered for a long time with nightly osteocopic pains in the 
right humerus, accompanied by fever and loss of flesh, and relieved by 
baths and mercurial inunctions. During slight salivation produced by 
the internal administration of the bichloride of mercury, and while the 
pain was still diminishing, he broke the arm in the middle by trying to 

■ Loccit., p. 22. 



00 ETIOLOGY OF FRACTURES. 

turn upon his right side. An "exostosis" was found extending from 
the elbow to the seat of fracture. Union took place within a month. 

A man of delicate constitution had a chancre and two buboes in 1814, 
followed by ulcers in the neck and pain in the bones. In 1816 he was 
treated twice in Berlin by inunctions, which reduced his strength greatly, 
but did not relieve his symptoms. His right arm, which had long been 
the seat of severe and constant pain, was then broken by slight violence, 
and the fracture did not unite. In 1818, being in a very wretched con- 
dition, he consulted Delpech, and was placed upon a tonic treatment, 
during which the fracture seemed to unite, but after a somewhat violent 
movement one day a new fracture was found two inches below the first. 
Sometime afterwards, the tonic treatment having been kept up mean- 
while, Delpech cut down upon the bone, found the upper fracture united 
by a pliable callus, and the lower one without a trace of union ; he re- 
moved at different times about three inches of the bone, which was soft 
and fragile, with thin walls and full of fat, and obtained fibrous union. 
Under mercurial and tonic treatment the syphilitic symptoms disappeared, 
but the left clavicle became the seat of severe pain and was broken in 
the centre by the effort made in putting on a vest ; this fracture united 
solidly, and was followed by another at the sternal end of the same bone, 
also preceded by severe pain. 

An apothecary, 1 38 years old, broke his right humerus while drawing 
a tooth. For a year previously he had suffered more or less with pain at 
the seat of the subsequent fracture, and the bone had seemed so weak 
that he feared to use it, although it had increased greatlv in thickness. 
He had also pains at night in his head and joints, and nodes upon the 
skull, and was taking the iodide of potassium. The fracture united 
promptly, but the arm remained useless. 

There seems to be no reason to suppose that mercury has any direct 
action upon the bones, rendering them more liable to fracture, and the 
most that can be claimed, is that its excessive, unskilful use will cause 
a general deterioration of the health, which may result in an atrophy of 
the bones, similar to that found in old age and in some paralytic condi- 
tions. 

Cancer. — There are two ways, apparently, in which the development 
of a cancer may lead to fracture of one or more bones : either the tumor 
may occupy the bone itself, primarily or secondarily, and destroy it to 
such an extent that the slightest force is sufficient to fracture it, or the 
presence of the tumor elsewhere may induce a cachexia which results in 
an atrophy of the bone similar to that found in the senile condition. 
The first stage of the development of a cancer in bone presents the 
changes of rarefying osteitis with substitution of granulation or fibrous 
tissue for the bone, the cancer cells then develop in this new tissue, as 
they do in fibrous tissue elsewhere. In a case of extensive generaliza- 
tion of cancer which came under my observation, portions of several 
ribs and vertebrae, a large part of the pelvis, and the upper portion of 
the right femur were so changed in texture, although their external form 

i W. Parker, in N. Y. Journ. of Med., July, 1852. 



ETIOLOGY OF FRACTURES. 



87 



Fiff. 55. 



was perfectly preserved, that a knife could be easily thrust through them. 
Under other circumstances the morbid growth seems to localize itself in 
the medullary canal, and to destroy the cortical layer by absorption ; 
when the latter is reduced to a thin shell, a very slight effort may frac- 
ture it. This occurred also in the case to which reference has just been 
made. The right femur was broken at the junction of the lower and 
middle thirds, by the patient turning in bed about a fortnight before his 
death. The external dimensions of the bone were unaltered at the seat 
of fracture, but it was reduced to a shell not more than a line in thick- 
ness, and its interior was filled by a mass of soft pink tissue, which ex- 
tended two or three inches along the medullary canal on either side of 
the fracture, widening it, and even perforating its wall in places. 

When the tumor is sufficiently large to be easily recognized from 
without, and to clearly account for the- fracture, even if not to cause it 
to be anticipated, we should look upon the fracture as an accident or 
epi-phenomenon of the tumor, rather than regard the tumor as a predis- 
posing cause of fracture ; but in the other class of cases, where the 
presence of the morbid change in the bone is not recognizable, when the 
fracture occurs without any warn- 
ing, and is the first thing that calls 
attention to the bone, or even, as 
in Louis's case, first brings to the 
surgeon's knowledge the existence 
of a cancer at another point, we 
may certainly class it with the 
other constitutional predisposi- 
tions. Gurlt 1 collected thirty-eight 
cases of this latter kind, of which 
the following may serve as ex- 
amples of the different varieties, 
modes of termination, and possi- 
bility of reunion. 

Louis 2 was called to see a nun, 
sixty years of age, whose arm had 
been broken by the efforts of a 
coachman to help her into a car- 
riage. Union did not take place, 
and six months afterwards, while 
seated in a chair, she broke her 
femur by letting her hand fall upon 
it. Louis, seeking the cause of 
this fragility, then learned, for the 
first time, that the patient had an 
ulcerated cancer of the breast. 

A woman, 3 forty years of age, 
who had a cancer of the breast 0ancer of the femur _ Fractare . (CrU veiiMero 




1 Loc. Cit., p. 184. 

2 Quoted also by Malgaigne, vol. i. p. 14. 

3 Cruveilhier's Anat. Path. Livraison XX. PI. I. fig. 4. 



88 ETIOLOGY OF FRACTURES. 

for some time, with well-marked cachexia, broke her right femur in the 
lower third by rising from a chair. She was taken to the hospital, and 
there the other femur was broken by the interne as he was preparing to 
apply a bandage to the first. She died the same night, and at the 
autopsy cancerous masses were found in the spongy tissue and in the 
medullary canal at the points of fracture and elsewhere (fig. 55), also 
in the vertebras and cranial bcnes. 

A woman, thirty-four years old, had an encephaloid tumor in the left 
axilla. She broke her left humerus with an audible snap by pressing 
against the side of the bed, and died three days afterwards. At the 
autopsy two ribs were found fractured, in addition to the humerus, and 
numerous cancerous nodules were scattered over the peritoneum, costal 
pleura, ribs, and abdominal viscera. There was no sign of any heterol- 
ogous growth in the broken humerus, and the other humerus was not 
brittle. 

A woman, 1 forty-nine years old, with tumors under the lower jaw, in 
both breasts, the uterus, and other organs, broke her right humerus 
while washing one of her children, then her left humerus while cutting a 
piece of bread, then the clavicle by throwing a book out of bed, then 
the right humerus again by rising in bed, and the left humerus again by 
tearing the burning clothing off a child. All the fractures united readily, 
with abundant callus. 

A woman, fifty-two years old, with ulcerated cancer of the breast, had 
her humerus broken by the efforts of the nurse to raise her in bed. Good 
union apparently in six weeks ; death by exhaustion in ten weeks. On 
inspection the fracture appeared to be healed, but on sawing the bone 
longitudinally, the broken ends were found unaltered in appearance in 
thickness, and inclosed in a rather thin bony ring. A mass of fibrous 
tissue, in which were imbedded numerous smaller masses, composed en- 
tirely of cancer-cells, filled the medullary canal at the seat of fracture, 
and similar small cancerous masses were found at other points of the 
canal. The cortical layer of the bone was eroded at points correspond- 
ing to the cancerous nodules, and in some places even perforated. Can- 
cerous nodules in the liver. 

A woman, forty-seven years old, broke her femur just below the 
trochanters by getting out of a wagon, fifteen months after a cancer of 
the breast had been removed by operation. Union took place in six 
weeks, and she died nine months afterwards of exhaustion. The autopsy 
showed that the upper portion of the femur had been changed into a 
large meshed network, with tenacious dirty-gray contents. The fracture 
had followed the intertrochanteric line, and the union had been accom- 
plished by interlacing spicule of bone passing from one fragment to 
the other. 

Of thirty-two of these cases in which the position of the primary 
tumor is noted, it occupied the mammary gland twenty-six times (once 
in a man); and of the entire thirty-eight cases thirty-five were women. 
As a rule, too, the affection was of long standing ; in many of the cases 
the tumor had returned after removal, and in nine it had ulcerated. 

1 Lancet, April 8, 1837. 



ETIOLOGY OF FRACTURES. 89 

The humerus and femur were almost exclusively affected, but in very 
unequal proportions — twenty-six fractures of the femur and seven of the 
humerus. Severe localized pain in the bone preceded the fracture in a 
number of cases. 

Reunion took place in one-fourth of the cases, and "in at least three of 
these there was cancerous degeneration of the bone at the seat of the 
fracture. In most of the remaining twenty-eight cases death, due to the 
progress of the disease, followed so soon after the accident that the bones 
had not time to unite, even if they were capable of carrying on the 
necessary processes. There is no reason to doubt the probability of re- 
union in cases where the recurrence of fracture has been favored by 
simple atrophy, for such reunion is the rule in other cases where similar 
atrophy has been induced by other causes ; but when the predisposing 
cause has been absorption of the bone by the growth of a cancerous mass 
within it, not only does the subsequent growth of the tumor, which is all 
the more rapid in consequence of the relief of pressure, continue the 
work of destruction, but the mass itself constitutes a mechanical obstacle 
to union by its interposition between the fragments, and, in addition, the 
destruction of the marrow and the reduction of the bone to a mere shell 
remove the two principal elements by which the process of repair is 
normally carried on. In the ossifying forms of cancer it is possible that 
trabecule starting from either end may unite with one another, and thus 
bind the fragments together, as occurred possibly in the last case men- 
tioned above. 

Hydatid and other Cysts ; Caries and Necrosis. — There are a few 
instances on record in which the unsuspected development of a hydatid 
cyst within a bone has resulted in its fracture by slight violence at the 
point occupied by the cyst ; and others in which a similar result has 
been produced by the occurrence of a cystic degeneration of unspecified 
character within the bone. These causes act by direct absorption of the 
cortical layer of the bone, not by a modification of its structure, and 
their effects are confined to the single bone and the single point involved 
by the disease. Facts of this kind deserve mention in this connection 
only on account of their resemblance to other cases in these respects, 
that the fracture is produced by slight violence, and no warning is given 
by change in the volume or functions of the limb. 

While caries and necrosis are among the most common of diseases, and 
often cause a very considerable loss of substance, Gurlt says the exam- 
ples of fracture during the existence of either condition are exceedingly 
rare. The reasons are apparently of two kinds : the disease is in itself 
of sufficient importance to require the affected limb to be kept more or 
less completely at rest, and thus withdrawn from exposure to the usual 
immediate causes of fracture ; and, secondly, the process is either ac- 
companied by compensatory ones which strengthen the bone by forming 
new tissue in the place of that which is destroyed, or it affects the short 
bones or the spongy ends of the long ones, which, as has been shown, 
are the least liable to be broken. When the shaft of a long bone becomes 
necrosed in whole or in part in consequence of an acute periostitis, or 
osteo-myelitis, the dead bone retains, not only its firmness, but also its 
connection with the living portions until an involucrum has been formed 



90 ETIOLOGY OF FRACTURES. 

about it, and this involucrum is ordinarily sufficiently large to resist effec- 
tually any fracturing violence to which it may be accidentally exposed. 
The chronic carious process often lasts for years without causing much 
loss of substance, and the bone is strengthened by condensation, ebur- 
nation, of the parts adjoining the cavity ; but when the process is more 
rapid, and the loss of substance is greater, involving almost the entire 
thickness of the shaft, fracture is likely to be caused if the limb is not 
handled with great care. Fig. 58 represents the lower end of a femur 




B 

Fracture of carious femur. A. Epiphyseal cartilage. B. Crucial ligament. C Point of fracture. 

removed by amputation after fracture in a case which came under my 
observation in 18T7. The patient was a lad of twelve years, who had 
been affected for some time with suppurative disease in the right femur 
and tibia ; a fistulous opening above the knee led to bare bone, and an 
operation was undertaken for its removal. After the bone had been ex- 
posed, and two small necrosed fragments removed, the surgeon tried to 
straighten the partly flexed leg. without using much force, however. A 
sharp crack was heard, and it was found that the bone had been broken. 
The figure shows that the lower fragment had been so bent by the pro- 
longed flexion of the knee and the traction of the posterior muscles of 
the thigh, that its articular surface was directed rather backwards than 
downwards. 

B. Immediate or Determining Causes of Fracture. 

These exist in every case of fracture, for a bone breaks only when 
the strain to which it is subjected is superior to its power of resistance. 
It is entirely immaterial whether this strain or this power of resistance 
is great or small, and therefore the term spontaneous, which is some- 
times applied to fractures produced by very slight violence, such as turn- 
ing in bed, ought to be abandoned, for it does not properly express the 
idea which it is intended to convey. 

The immediate cause of a fracture may be either a force acting from 
outside the body, as in a blow or a fall, or one originating within the 
body, and exerted directly upon the bone which is fractured by the 



ETIOLOGY OF FRACTURES. 91 

action of muscles attached to or closely connected with it. Those pro- 
duced by the first cause are called fractures by external violence ; those 
by the latter, fractures by muscular action. 

a. Fractures by external violence. The division of these into two 
classes, of which one is called fractures by direct, the other fractures by 
indirect violence, is based upon clinical differences often of extreme im- 
portance, and not simply upon mechanical differences in the mode of 
transmission and in the effect of the applied force. This relieves us, 
therefore, from the necessity of examining into the latter questions with 
their many obscure factors and complex relations, and makes the defi- 
nitions simple. A fracture by direct violence is one, surgically speaking, 
in which the bone is broken immediately under the point upon the sur- 
face where the fracturing violence is received ; and a fracture by indi- 
rect violence is one in which the fracture takes place at a distance from 
that point. Thus, a fracture of the leg by a blow with a heavy bar, by 
the passage across it of a wheel, or by the impact of a rifle-ball, is a 
fracture by direct violence, while a fracture of the thigh by a fall upon 
the feet, or of the clavicle or humerus by a fall upon the hand, is a frac- 
ture by indirect violence. The most important clinical difference between 
the two varieties depends upon the injury to the overlying soft parts in 
the one case, and the absence of such injury in the other, upon the prob- 
ability that in the former the fracture will be compound, and will suppu- 
rate on account of the bruising and subsequent sloughing of the soft 
parts, and that in the other it will be simple, or if compound may not 
suppurate, and may run the course of a simple one. In addition, frac- 
tures by direct violence are more likely to be comminuted and to be 
accompanied by serious injury to adjoining vessels and nerves, which 
may necessitate amputation. 

It is worthy of remark that the skin is not always broken in fractures 
by direct violence, even when the vulnerant force has been extreme and 
the injury to the soft parts under the skin very extensive. The tough- 
ness and elasticity of the skin sometimes preserve it, especially when 
the body that exerts the violence acts over a large surface, and does not 
present sharp angles or edges. The passage of the wheel of a heavily 
laden wagon across the leg may crush both bones into splinters and re- 
duce the muscles to a pulp without breaking or even apparently injuring 
the skin. On the other hand, the blow may break the skin at the point 
where it is received and produce fracture by indirect violence at a greater 
or less distance, the bone yielding at its point of least resistance, and 
not at that where the force is directly exerted. 

The fracturing force may be applied directly or indirectly to the bone 
(causing compression, splitting, or penetration), or obliquely to its long 
axis, or as torsion, or as avulsion. Examples of the first are furnished 
by falls upon the feet with fracture of the calcaneum, gunshot wounds, 
impacted fracture of the lower end of the radius or of the upper end of 
the humerus with penetration of the epiphysis by the hard shell of the 
shaft, of the second by most fractures of the shafts of long bones, of the 
third by some fractures of the leg where the foot is fixed and the body 
turned forcibly about it, and by others in which the fracturing force is 
due wholly or in part to the action of muscles attached to the side of the 



92 ETIOLOGY OF FRACTURES. 

bone and exerted in a plane that is not parallel to its axis, and of the 
fourth by fracture of either malleolus by lateral displacement of the foot. 
The mechanism. in direct fractures produced by falls or by blows is the 
same, for from a mechanical point of view it is indifferent whether the 
force is developed by the movement of the limb or of the external object 
with which it comes into contact. 

Indirect fractures are by far more common in long bones than in short 
ones for reasons that have been considered already in the section on 
form and function considered as predisposing causes of fracture. The 
principle of their production, which was also mentioned in the same sec- 
tion, is that of the transmission of a force along a bone or set of bones 
made rigid by ligamentary attachments or muscular contraction in such 
manner that it is resolved into forces acting in two or more directions, 
one of which crosses the long axis of the bone and acts as if it had been 
applied directly at the point of least resistance in a lateral or transverse 
direction. The effect is modified greatly by the anatomical structure 
and form of the bone, the attitude of the limb, the contraction of the 
muscles, and the direction of the blow. Thus, a fall upon the hand may 
break the lower end of the radius, both bones of the forearm, the hume- 
rus, or the clavicle ; a fall upon the foot may fracture the calcaneum by 
direct violence, or the bones of the leg, the thigh, or even the vertebral 
column or skull by indirect violence. Pressure against the sternum may 
break the ribs by exaggerating their curves ; pressure against the wings 
of the pelvis may produce a similar result. 

The best example of the fracture of short bones by indirect violence is 
furnished by the spinal column, the bones of which, considered as a 
group, constitute a long bone with several curves, resembling the clavi- 
cle in its entirety and in the mechanism of its fractures so far as they are 
produced by exaggeration of a normal curve. 

Indirect fracture by traction upon a bone occurs exclusively at apophy- 
ses which give attachment to strong ligaments through which the force is 
conveyed. Thus, the internal malleolus is torn off by the forcible rota- 
tion outward (eversion) of the sole of the foot ; the internal lateral liga- 
ment is put upon the stretch, and if, as is usually the case, its attach- 
ment to the bone is stronger than the cohesion between the particles of 
the bone itself the latter yields and a transverse fracture results. A 
similar mechanism is sometimes found at the elbow on the inner, and pos- 
sibly also on the outer, side. 

b. Fractures by muscular action. Under this head are included only 
those fractures in which the rupturing . force is exerted by the muscles 
alone without the aid of any external violence. It is of course evident 
that if an individual breaks his skull or a limb by running or striking 
against a solid object the force that causes the fracture is developed by 
the action of his muscles, but the mechanism is the same as if he had 
fallen from a height or as if his body was at rest and the object with 
which he has come into contact was in motion. Only those cases are 
considered to be fractures by muscular action in which the action is ex- 
erted directly by the muscles upon the bones to which they are attached 
(mediately or immediately), either as direct traction, or in fracture of 
the patella or of the olecranon, or obliquely, according to the principle 



ETIOLOGY OF FRACTURES. 93 

of the lever, or by exaggerating the normal curve of the bone by drawing 
upon one of its extremities. Mention has already been made (page 74) 
of the influence exerted by the contraction of the muscles in favoring the 
production of fracture by external violence, an influence which is demon- 
strated experimentally by the extreme difficulty of producing the common 
indirect fractures in a cadaver by throwing- it from a height, and which is 
explained in part by the fact that the muscles when rigid hold contiguous 
bones together so closely and so firmly that they practically form one 
long bone more or less curved and therefore more exposed to fracture by 
over-bending, and in part by the additional strain which the muscles 
exert upon the bones. 

Some authors have expressed the opinion that no bone can be broken 
by simple muscular contraction unless it has previously undergone some 
change that has diminished its strength, but this opinion must be looked 
upon as an attempt to explain away by an unfounded, or at least un- 
proven, assumption a difficulty which does not really exist. It is un- 
questionable that in all cases of fracture by slight muscular action a pre- 
vious change in the strength of the bone must have taken place, and in 
many of them this change has been demonstrated by direct examination. 
Several such cases have been described under the different predisposing 
causes of fracture. But it is no more logical to claim that such a change 
has preceded every fracture by muscular action than it would be to 
make the same claim for fractures by external violence ; it can rest only 
upon the assumption that the power of resistance of a normal bone is 
superior to any force that a muscle or group of muscles can exert upon 
it under the most extreme and unusual circumstances, whereas, on the 
contrary, nature's precautions and adaptations are as a rule calculated 
upon the basis of the probable, not of the exceptional. Such a position 
may be taken with propriety with reference to all fractures produced by 
slight causes in the old, the weak, or the cachectic, or in those who have 
suffered pain at the point of fracture for some time previous to the acci- 
dent, but it is entirely unsupported by proof in the rarer, but still suffi- 
ciently numerous, cases of fracture of the shaft of a long bone produced 
by a violent effort in a healthy athletic man, and in the common ones of 
fracture of the patella or olecranon. 

The effect of muscular action is manifested in all the degrees of vary- 
ing importance between its relatively unimportant additions to the effects 
of external violence, and those cases in which it is the sole agent of 
the fracture of a healthy bone. The intermediate degrees are presented 
by those fractures, usually of weakened bones, in which moderate mus- 
cular action has acted either alone or combined with some external vio- 
lence. In the first case, when the power of the muscle is exerted in the 
same direction as the external violence, it increases the fracturing force 
by just so much : and, by prolonging its effect after the fracture has been 
made, it also increases the displacement of the fragments and the lace- 
ration of the soft parts. The principal interest of the intermediate cases 
is connected with the cause of the exceptional fragility of the bone, and 
as it has been previously discussed, with illustrative examples, in that 
connection, it does not require further attention here. 

The commonest examples of fracture by muscular action alone are 



94 ETIOLOGY OF FRACTURES. 

furnished by the patella and the olecranon, and similar, but rarer, exam- 
ples have also been given by other apophyses to which powerful muscles 
are attached, such as the posterior portion of the calcaneum, the coronoid 
process of the ulna, and the coracoid process of the scapula. These 
fractures are almost exactly transverse, and in most cases show that the 
resistance of the bone to direct traction is less than that of the tendons 
through which the traction is exerted. The patella is a sesamoid bone 
developed within a tendon, and is practically the weakest point in it, for 
the great majority of the cases of its fracture are, apparently, fractures 
by direct muscular action unaided by any leverage ; the bone is broken 
as a rope is, by direct traction upon it. 

Of the long bones the humerus is the one most frequently broken in 
this manner ; out of 85 cases of fracture of the limbs by muscular action 
collected by Gurlt 1 57 were fractures of the humerus, 15 of the thigh, 
8 of the leg, and 5 of the forearm. He gives also some remarkable 
cases of fracture of the sternum and of the vertebral column by unaided 
muscular action. The mechanism seems in most cases to be the same as 
in indirect fracture ; in some the fracture takes place at the point of 
insertion of the muscle, and in others the elements are too complex and 
too uncertain to be explained theoretically. In a comparatively small 
number of cases the fracture was caused by the convulsions of epilepsy 
or tetanus, and in others by reflex contractions or spasms in limbs that 
had been long paralyzed, but usually the cause was a violent voluntary 
muscular effort to avoid a fall, or to throw a stone, or lift a heavy object. 
The following cases taken from Gurlt illustrate the different fractures 
and the different methods in which they may be produced. It must be 
remembered that fractures produced during convulsions need to be closely 
examined in order not to overlook the possible addition of external vio- 
lence by a fall from the bed or by striking the limb against a solid object. 

In a negro boy, twelve to thirteen years of age, affected with tetanus, 
both thigh bones were broken " at the neck," probably just below the 
trochanter, by the contraction of the muscles, and the tragments forced 
through the skin on the outer side of the limb. An inch had to be 
removed from one of the bones before reduction could be effected. 
Recovery with angular displacement followed. 

Lente 2 reported a case of fracture of both femurs at an interval of 
eight months in a child twelve years old, during epileptic fits. The 
fractures w T ere at the junction of the upper and middle thirds of the 
bone ; the first united with considerable shortening ; the patient died six 
weeks after the occurrence of the second fracture, which had not united. 

The majority of the recorded fractures of the humerus were produced 
by the effort of throwing some object, a ball or a stone, with violence, 
and Gurlt thinks the mechanism is the same as that by which a stick is 
broken when it is grasped at one end and snapped sharply like a whip. 
The contraction of the deltoid arrests the bone suddenly and the impetus 
of the lower end of the humerus causes the break, which, however, may 
take place at either end or at the middle of the bone. 

1 Loc. cit., vol. i. p. 232. 

2 Am. Med. Times and Advertiser, July 21, 1860, quoted by Hamilton. 



ETIOLOGY OF FRACTURES. 95 

An athletic man, 1 thirty-four years old, accustomed to lift heavy 
weights, broke his humerus with an audible snap just below the insertion 
of the deltoid by the effort made, on a wager, to throw a stone weighing 
about two ounces the distance of a hundred yards. Eecovery in six 
weeks. 

An apparently robust and healthy man, 2 twenty-one years old, broke 
his humerus in the lower third by throwing an oyster shell with some 
force out upon the ice from the bank of the river. Recovery in the 
usual time. 

A powerful and healthy student 3 broke his humerus in two places in 
a duel while making the stroke known as u Quarte." 

Gurlt gives also eleven cases in which the humerus was broken during 
that trial of strength in which two men place their elbows upon a table, 
clasp hands with the forearms parallel and vertical, and strive to force 
each other's hand backwards. In almost all these cases consolidation 
took place within the usual limits of time. 

Fractures of the femur are rarer than those of the humerus. They 
may occur at any point on the shaft, and in the recorded cases have been 
the result of an attempt to kick, to avoid a fall, or to rise from the ground 
without aid, or of cramps, excited in one case by drawing on a tight boot, 
and in another by turning in bed. 

A colonel of cavalry, 4 36-38 years old, of middle size and great 
muscular power, broke his thigh at the junction of the upper and middle 
thirds by kicking at and missing his servant. 

Barnard Van Oven, 5 described before the Royal Medical and Chirur- 
gical Society, a fracture of the thigh sustained by himself. He was 56 
years old, healthy and strong, and free from taint of cancer, scrofula, 
syphilis, etc. He was awakened one night by a sharp, cramp-like pain 
above the knee, and as he felt the part with his hand and noticed that 
the muscle was tense, he heard a snap, followed by relaxation of the 
muscle, crepitation, and diminution of the pain. Examination showed a 
transverse fracture of the lemur three inches above the knee ; complete 
recovery in four months. 

A cavalry man, 6 29 years old, while trying to rise from a sitting posi- 
tion on the ground without the aid of his hands, broke his right thigh 
transversely at its middle. A diseased condition of the bone could not 
be show T n. 

Hamilton 7 reports a fracture of the shaft of the femur in a large and 
perfectly healthy man, occasioned by a twist of the leg in rolling ten- 
pins, and Gurlt mentions an unrecorded case of fracture of the thigh at 
two points, produced by a similar cause, in a not entirely healthy man 
of 35 years. 

Gurlt's eight cases of fracture of the leg comprise four of both bones, 

' Guthrie, Lond. Med. and Surg. Journal, 1835, vol. vi. p. 478. 

2 Kirkbride, Am. Journal Med. Sciences, 1835, vol. xvi. p. 33. 

3 Keil, De Fragilitate Ossiuru, etc. Vratislav, 1845, p. 23. 

4 Journal universel des Sciences Med., t. xi. p. 373. 

5 Lancet, 1852, vol. ii. p. 591. 

6 Gaz. Med. de Paris, 1842, p. 218. 

7 Fractures and Dislocations, 3d ed. p. 30. , 



96 ETIOLOGY OF FRACTURES. 

one of the tibia, and three of the fibula alone, the latter being fractures 
at the upper end of the bone by the vigorous contraction of the biceps. 

A small rather corpulent woman, 45 years old, slipped on the left foot 
while descending some steps, made a violent effort with the right leg to 
avoid a fall, felt at once a very severe pain in the latter, and fell in a 
sitting posture upon the bottom step. An immediate examination 
showed a fracture of both bones at the middle of the leg, the muscles of 
the calf strongly contracted, and a small wound of the skin over the 
anterior angle formed by the fragments. 

A woman, 1 52 years old, mistook in the dark a door leading into the 
cellar for one opening into a closet, and, recognizing the mistake as she 
put her right foot forward, drew herself instinctively backward, and felt 
at the same moment something snap in her left leg, upon which the 
weight of her body rested. She fell and rolled down the steps. On. 
examination, a fracture of the left fibula just below its head was found. 

Fracture of either or both bones of the forearm has been caused by 
the wringing of wet clothes, or by shovelling. The accident is among 
the rarest of fractures by muscular action, only five cases being reported 
by Gurlt. 

A healthy girl, 2 18 years old, while wringing clothes, felt a sudden, 
sharp pain on the inner side of the forearm above the wrist. Three 
days afterwards a fracture of the ulna 67 millimetres (2J inches) above 
the wrist was recognized by the abnormal mobility and crepitation. 
Union in a month. A year previously she had dislocated the lower end 
of the ulna backwards, which must have interfered with the movement of 
supination. 

A woman, 3 30 years old, broke the radius in its lower third with 
severe pain, while wringing two heavy towels. Recovery in 36 days. 

A healthy, powerful lunatic, 4 while using a shovel heard two distinct 
snaps in his right forearm, and found himself unable to use the limb. 
The next day Malgaigne found a fracture of the radius near its centre, 
and a fracture of the ulna about an inch nearer the wrist, w r ith consider- 
able displacement. 

Fractures of the clavicle have been caused by the effort of raising a 
heavy object, shovelling, and striking backwards, or with a whip. 

Malgaigne 5 reports two cases of fracture of the clavicle caused by an 
effort to toss a heavy body upwards ; one in the outer half of the bone 
in a man 41 years old ; the other in the inner third in a youth of 18 years. 

Gosselin 6 reports a case of fracture of the clavicle in its middle third, 
caused by the effort to raise a heavy piece of marble and place it upon 
the shoulder of a fellow workman. 

Fractures of one or more ribs are not infrequently caused by violent 
coughing. The sternum has been broken in four recorded cases by the 
violent straining and bending backwards of the body during the expul- 
sive efforts of parturition, and there are three or four cases of fracture 

1 Revue Med. Chirurg. de Paris, t. xvi. 1854. 

2 Labatt, Dublin Med. Press, 1840, and Gaz. Medicale, Paris, 1840, p. 475. 

3 Gazette des Hopitaux, 1844, p. 224. 

4 Malgaigne, Fractures and Luxations, vol. i. p. 585. 

5 Loc. cit., p. 464. 6 Clinique Chirurgicale, 1873, vol. i. p. 413. 



ETIOLOGY OF FRACTURES. 97 

of the vertebral column by muscular action alone, 1 and four of the 
scapula. 

Monteggia 2 saw a man 50 years old who had broken a rib by violent 
coughing. The crack was heard by members of the family present in 
the room. No further details. 

Hilton 3 reports the case of a man who broke a rib by muscular action 
while trying to mount a spirited horse. He was treated for a long time 
for pleurisy before the fracture was recognized. 

A primipara, 4 24 years old, taken in labor sought to hasten delivery 
by forcible voluntary expulsive efforts, bending backwards and resting 
on her elbows and heels. During this effort she felt a sudden sharp 
pain and a snap in the middle of the breast, and said at once that some- 
thing had broken there. No attention was paid to the statement until 
five days afterwards when, peritonitis having appeared, an examination 
w T as made and a painful swelling found in the upper portion of the ster- 
num, with quick and difficult respiration and increased pulsation in the 
large vessels. The patient died on the 17th day, and at the autopsy a 
transverse fracture of the sternum was found 1J lines above the junction 
of the body and the manubrium. The edges of the fracture were separ- 
ated, and an inflammatory exudation as large as a hen's egg and con- 
taining pus was found in the anterior mediastinum. 

A soldier 5 bathing in the Sambre dived into the river, and, not reap- 
pearing, was sought for and brought out. His body showed no trace of 
external violence, but there was paralysis of all the limbs, loss of sensa- 
tion, inability to hold up the head, pain at the posterior and lower part 
of the neck, priapism, frequent desire to urinate. He said that as he 
dived he saw the water was too shallow, and in the effort to avoid strik- 
ing against the bottom he jerked his head violently backward and at once 
lost consciousness. He died the same night, and the autopsy showed a 
transverse fracture of the body of the 5th cervical vertebra a little below 
its centre ; the cord and dura mater were intact, but there was an exten- 
sive extravasation of blood between the latter and the bone and also on 
the outside of the column. 

A servant 6 engaged in preparing a lamp raised his arm quickly to 
arrest the action of an escaping spring and felt something give way in it. 
The arm fell powerless by his side, and the greater portion of the acro- 
mion was found to have been broken off; crepitation very distinct. Re- 
covery in six weeks. 

C. Intra-uterine Fractures and Fractures during Delivery. 

Fracture of the limb of a child during its delivery through the natural 
passages of the mother is of rather frequent occurrence and is usually 
the result of manual or instrumental interference to correct a faulty pre- 
sentation or to supplement the insufficient expulsive power of the uterus. 
Such fractures belong to the class of fractures by external violence and 

1 See Fractures of the Vertebrae, chap. xiii. 2 Archives Generates, 1S38. 

3 Lancet, 1852, vol. i. p. 143. 

4 Chaussier, Revue Med. franc et etrang, t. iv. 1827, p. 264. 

5 Reveillon, Arch. Gen. de Med., 1827, t. xiii. p. 449. 

6 Wildbore, Loud. Med. Gaz.. New Series, 1846, vol. iii. p. 708. 

7 



98 ETIOLOGY OF FRACTURES. 

present no features of especial interest ; but there are others in which 
the fracture is caused by the expulsive efforts of the mother alone. An 
arm or leg is engaged between the body of" the child and the rigid parts 
of the mother and the humerus or femur broken, sometimes with an audi- 
ble snap, as the child is forced through the passage. Thus, in one case 
during the spontaneous delivery of the shoulders, the arm, which lay 
across the child's breast, was heard to snap and a fracture was found at 
its upper third; in another, a breach presentation with very forcible 
pains, the femur was broken by pressure against the symphysis pubis ; 
and in a third, where the head and left hand presented simultaneously 
and were violently forced through the pelvic outlet, a fracture of the left 
humerus was found. 

Fractures within the uterus have been caused in a few cases by a bul- 
let or sharp instrument that has at the same time perforated the abdom- 
inal wail of the mother; the interest attaching to them, however, is 
statistical rather than practical, for in the three cases collected by Gurlt 
miscarriage followed, with death of the foetus in every case, and of the 
mother in one. 

The possibility of the occurrence of fracture within the uterus as the 
result of external violence without perforation of the abdomen of the 
mother, or, in some cases, of unknown causes, has been proved by the 
delivery of children presenting fractures of different bones in various 
stages of repair. It is not always easy to say, when a child is born 
with a fracture, whether it was caused during the delivery or at an ear- 
lier period, or whether it was due to external violence or to the contrac- 
tions of the uterus. And furthermore, it is not always possible to say 
whether the apparent fracture is actually one or only a malformation, a 
defect of ossification or development, or a separation of the epiphysis 
in consequence of a syphilitic or inflammatory process. Gurlt collected 
eight cases in w r hich the causal relation between an injury received by 
the mother during pregnancy and the fracture observed in the child 
seemed to him to be clearly demonstrated, and twenty-five others in 
which more or less doubt existed as to the cause of the fracture or the 
character of the lesion. The injury in the first eight cases was either 
a fall from a height or a direct and violent blow upon the abdomen; and 
the bones broken were those of the thigh, leg, arm, and forearm, and 
the collar bone. The autopsy in three cases showed union of the frac- 
ture with undoubted callus and more or less overriding of the fragments ; 
in three others the fracture had led to suppuration and perforation of the 
skin, and in two there was a large callus (humerus and clavicle). 

'The remaining cases include some in which an undoubted fracture 
existed, but with no history of external violence, and some in which the 
coexistence of malformations threw some doubt upon the character of the 
supposed fracture, and others in which the fractures were so numerous 
and so symmetrical that they must have depended upon some general 
cause acting probably upon the epiphyseal cartilages. It has recently 
been shown by Parrot, as the result of his researches concerning the 
lesions of syphilis in infancy, that this disease has a marked tendency 
in the foetus and infant to atfect the tissues by which the growth of the 



ETIOLOGY OF FRACTURES. 99 

bone is carried on, and to weaken the connection between the shaft and 
the epiphyses. 

A woman gave birth prematurely to twins, one of which presented an 
old fracture of the femur. The bone projected more than an inch through 
the skin and was carious. About six weeks before delivery the mother, 
while making some slight exertion, heard something snap in her abdomen, 
and felt thereafter, on every movement, a pricking as by the point of a 
knife. 

Blasius 1 reported the case of a healthy, well-formed child with an 
obtuse angular deformity at the junction of the lower and middle thirds 
of one leg ; the skin presented a cicatricial-like retraction at the angle, 
where it was also unusually adherent to the bone. The ankle was free, 
the heel drawn up, and the inner border of the foot directed upwards. 
The limb was smaller than the other, and had only two toes and two 
metatarsal bones in the foot. There was a doubtful history of a blow 
received upon the abdomen during pregnancy. 

Chaussier saw in 1813 a child that died twenty-four hours after deliv- 
ery, whose skeleton presented 113 solutions of continuity, 70 of which 
were in the ribs ; a considerable number had become consolidated. 

Hedland saw in the child of a woman who had had a violent fall during 
pregnancy both femurs broken near the neck, both tibias and fibulas 
just below the knee, and both arms near the elbow. The lesions on the 
two sides corresponded closely in position. At each fracture there was 
some pinkish pus, and the ends of the bones were roughened. Probably, 
as Gurlt suggests, this was a separation of the epiphyses due to an 
inflammatory process of unknown origin. 

Gurlt 2 gives the following as the only one of the cases of so-called 
self-amputation in which there is any probability that the loss of the 
member was due to a fracture accompanied by laceration of the soft parts 
or compression of the main artery sufficient to cause gangrene. 

A pregnant woman thirty-three years old fell from the top of a ladder, 
and lay unconscious upon the ground for some time. During the follow- 
ing days blood, and afterwards bloody water, escaped from the vagina, 
but she suffered no abdominal pain and continued to feel well. Delivery 
took place in due time, eight weeks after the accident. All the left 
upper extremity of the child below the middle of the arm was lacking, 
and the end of the remaining portion of the humerus projected slightly 
through a reddish-brown, moist, but not bleeding or suppurating wound 
which formed the surface of the stump and which cicatrized promptly. 
The amputated portion of the limb came away with the afterbirth ; it 
was composed of the hand, forearm, and lower portion of the arm ; its 
skin was shrunken, the nails complete, extensive extravasation of blood 
in the subcutaneous tissue, and the end of the humerus, which presented 
a toothed surface of fracture, projected about one-fourth of an inch. 

1 Monatschrift fur Grelrartsk. unci Frauenkrankheiten, Bel. xii. 1S5S, p. 129, quoted 
by Gurlt. 

2 Loc. cit., vol. i. p. 122. 



100 SYMPTOMS AND DIAGNOSIS. 



CHAPTER V. 

SYMPTOMS AND DIAGNOSIS. 

The symptoms produced by a fracture, the facts upon the existence or 
absence of which the surgeon relies in making a diagnosis, are divided 
in accordance with the common semiological practice into two groups, 
the objective and the subjective or rational. The symptoms included in 
the former are those which can be directly observed by the surgeon ; in 
the latter they are those for his knowledge of which he has to depend 
more or less completely upon the statements of the patient. The former 
are the most important and are the only ones which have a valid claim 
to be considered pathognomonic; they include, 1st. deformity of the limb 
or part, 2d. abnormal mobility at the point of fracture, 3d. crepitation. 
The second group includes, 1st. pain, 2d. disturbance of function or loss 
of power, 3d. history of the case and of the patient. 

Except in those comparatively infrequent cases, where the injury or 
the deformity of the limb is of such a character that the diagnosis is not 
for an instant in doubt, the symptoms of a fracture are not so promi- 
nent that a careful examination can be dispensed with, and in some 
cases they are so obscure that even the most experienced and skilful 
surgeon may remain in doubt. An examination should always be con- 
ducted systematically and thoroughly, and the appearances presented 
by the injured limb should always be compared with those of its unin- 
jured fellow, both for the easier detection of slight changes and to avoid 
the mistake of thinking some chance congenital variation to be a result 
of the injury. If the pain is so great as to prevent the necessary explo- 
rations, an anaesthetic, preferably ether, should be used, especially if 
the suspected fracture is in the vicinity of a joint ; and if the swelling 
of the soft parts masks the bones and interferes with the examination, 
the decision should be postponed for a few days until the swelling shall 
have been reduced by poultices or cooling lotions. In doubtful cases 
the question should always be asked whether the affected limb or its 
fellow has suffered any previous injury that might have altered its form, 
for otherwise a sprain or a contusion in the neighborhood of a deformity 
remaining after the healing of an old fracture might be mistaken for a 
recent fracture, or the limb which is used for the purpose of comparison 
may itself have been shortened or otherwise deformed by a previous injury. 

Objective Signs. 

Deformity. — This term is here employed in its widest sense to include 
changes in the relations of the fragments of the bones to each other and 



OBJECTIVE SIGNS. 101 

the modifications in the appearance of the limb or part of the body pro- 
duced by' those changes, by the effusion of blood, and by the later inflam- 
matory processes. In other words, it includes changes in the length 
and diameter of a limb, in the form and color of a surface, in the resis- 
tance of the tissues to pressure, and in the relations of certain bony 
points or prominences to each other. 

The changes in the relations of the fragments to each other and the 
resultant modifications of the form of a limb, have been described in 
detail under the head of Displacements (Chap. III.). Many of them are 
so marked that they are recognizable by simple inspection of the part, 
while others are brought to light only by careful measurements and 
comparison with the opposite limb. These measurements are used in 
practice only to recognize longitudinal and lateral displacements and 
those by which a limb is shortened or the diameters of an articular ex- 
tremity modified. As a rule, to which there are few exceptions, men- 
suration, to be of value, requires that the injury should be confined to 
one limb, to one side of the body, in order that the other may serve as 
a standard of comparison by which the change in the first may be recog- 
nized. The reason of this is the absence of fixed proportions between 
the different parts of the skeleton, such as would enable us to calculate 
in any given case from the height of an individual, for example, the 
length of a bone or the distance between any two points. Among the 
possible exceptions to this rule are the relations of the great trochanter 
of the femur to a line drawn from the tuberosity of the ischium to the 
anterior superior spine of the ilium, and those of the styloid process of 
the radius to the lower extremity of the ulna, both of which may be 
used with considerable accuracy in cases of fracture of the neck of the 
femur or lower extremity of the radius even when the opposite limb has 
been rendered unsuitable for the purposes of comparison by disease or 
injury. 

The chief difficulty in employing mensuration is that of finding fixed 
and well-defined points upon the body between which the desired 
measurements can be made. The ones employed in fractures are bony 
prominences or edges sufficiently near the surface to be readily recog- 
nized and felt, but as they are all more or less rounded, absolute accu- 
racy in measuring the distance is impossible. 

Another cause of error or of uncertainty lies in the differences which 
have been found to exist often in the limbs of the same individual, and 
which sometimes are very considerable. The occasional existence of 
such a difference not having a traumatic or pathological origin appears 
to have been known for some time. Duparque 1 published a paper in 
1863 in which he called attention to the influence of certain professions 
in diminishing the growth of one arm, as compared with the other, and 
to the importance of the recognition of this fact in the diagnosis and 
treatment of fractures. Although he refers to it as a fact generally 
known to the profession, I do not find it mentioned in the general trea- 
tises on surgery or the special ones on fractures ; and, in this country at 
least, attention was first called to this natural asymmetry in the length of 

1 Graz. Hebdornadaire, 1863, p. 55. 



102 SYMPTOMS AND DIAGNOSIS. 

the lower limbs in a paper published in the American Journal of the 
Medical Sciences, April, 1873, by Dr. Wm, C. Cox, and inspired by 
Prof. Thomas G. Morton, of Philadelphia, and subsequently, February, 
1877, but independently, by Dr. Wight, of Brooklyn. The statements 
then made have been since confirmed by many observers, and the exist- 
ence and diagnostic importance of a normal asymmetry are now gen- 
erally recognized. Prof. Morton 1 examined 51 3 boys, from eight to 
eighteen years of age, and found inequality of the lower limbs in 272, 
varying from J inch in 91 cases, and J inch in 100, to 1J- inch in 2 cases, 
and 1-f inch in 1 case. In a personal adult case, verified by dissection 
(one of a series of 16 cases examined in the dissection room in 1877), 
the distance from the anterior superior spine of the ilium to the tip of 
the external malleolus was half an inch greater on the right side than on 
the left, and the bones showed no trace of injury ; and in a case now 
under my observation at Bellevue Hospital the left humerus is half an 
inch longer than the right. It is evident, therefore, that small differ- 
ences, say up to half an inch, must be accepted with much reserve in 
making a diagnosis, or in estimating the result after repair. 

Other difficulties and causes of error in measuring are found in the 
swelling of the soft parts of the injured limb, which may prevent the 
measuring-tape from being drawn straight, and in the varying angles 
between the axis of the limb and the line of measurement. The first is 
not likely to be great, and is still less likely to be overlooked ; but the 
latter is a frequent source of error. It is rare that the two fixed points 
between which the measurement is made are both upon the limb, or the 
bone, whose length is in question ; one of them is usually upon the 
trunk, and lies at a certain distance from the centre of motion of the 
limb. Consequently any change in the position of the limb changes the 
actual distance between the two fixed points that have been chosen. For 
example, in measuring the length of the lower extremity the points 
taken are the anterior superior spine of the ilium and the tip of the ex- 
ternal malleolus ; the former lies several inches above and to the outer 
side of the centre of motion of the coxo-femoral joint, and therefore 
when the limb is in abduction the distance between the two fixed points is 
less than when the limb is parallel to the long axis of the body. If a 
comparison is to be made between the two limbs, it is essential that their 
positions with reference to the pelvis should be the same, and therefore 
care must be taken that the ankles are equidistant from a line drawn at 
right angles to another connecting the two anterior superior spines. It 
is not sufficient that the limbs should be parallel to the long axis of the 
body, for the pelvis may be inclined to it, and a glance at fig. 57 will 
show the result of such an inclination, one limb being virtually abducted 
and the other adducted, so that while the lines A B and A B, which repre- 
sent "the actual length of the two limbs, are equal, the lines C B and C B, 
which are the ones measured by the surgeon, are unequal. If only one 
upper fixed point in the median line, as the umbilicus or the sternum, is 
used for both measurements the effect of an inclination of the pelvis 
would be still greater. 

1 Surgery in the Pennsylvania Hospital, 1880, p. 287, 



OBJECTIVE SIGNS. 



103 



Fi«?. 57. 



Similar difficulties and uncertainties exist in transverse and peripheral 
measurements of the limbs to an even greater degree. The swelling of 
the soft parts not only increases the bulk of the part, but it also obscures 
the bony prominences, and places them at a greater distance below the 
surface, so that an accurate measurement of the distance between points 
upon the opposite ' sides of a bone is practically 
impossible. Malgaigne recommends the use of 
needles or pins passed through the soft parts until 
they touch the bone as a means of measuring the 
thickness of the overlying tissues. By subtract- 
ing the sum of these measurements from the diame- 
ter of the limb at that point the breadth of the 
bone is obtained. Theoretically the method is cor- 
rect, but the practical difficulties are great, for the 
very swelling which renders the method necessary 
obscures the land-marks, and makes it impossible 
to insert the needles with accuracy at the desired 
points. For this and for angular and rotatory dis- 
placements the trained eye of the surgeon, aided 
by careful and minute consideration or palpation 
of the anatomical land-marks and comparison with 
the other limb, is the best guide, and will often 
recognize the change at the first glance. 

The appearance of the limb may be still further 
modified by an abundant extravasation of blood 
poured out from the vessels of the bone and the 
adjacent parts, and either collected in a mass or 
infiltrated among the tissues. Except when the 
bone is subcutaneous, this extravasation is not 

at first accompanied by discoloration of the surface, and is then to be 
recognized only by the greater size and firmness of the limb, or pos- 
sibly by the peculiar crackling of the coagulated blood felt when the 
part is handled, a crackling which has been compared to that of dry 
starch, or of snow compressed in the hand. The swelling may be so 
distinctly limited, and rendered so firm by coagulation or the tenseness 
of the tissues that cover it, as to give to the exploring hand the sensa- 
tion of a solid substance, and thus be mistaken for the displaced end of 
the broken bone. Malgaigne has reported a case in which he mistook 
such a collection of blood for the projecting end of a broken femur. In 
case of doubt the diagnosis could be made by the aid of acupuncture 
needles, the introduction of which through the skin would show the con- 
sistency of the mass, and prevent a collection of blood from being mis- 
taken for bone. A similar diagnostic use of needles has been suggested 
when doubt exists as to the presence of a fissure, or as to the identity or 
connections of some portion of bone, or bony prominence, that can be felt 
through the skin, but it is doubtful if much can be gained by this method 
of exploration. It is, of course, possible that the point of a needle 
might slip into a fissure or pass between two fragments in such a manner 
that it might be alternately pinched and freed by bending the limb, but 
it is improbable that the occasion would often arise when the value of the 




104 SYMPTOMS AND DIAGNOSIS. 

information to be gained would justify even the slight inconveniences of 
the exploration, except in the contingency first mentioned, that of doubt 
as to the character of an abnormal mass, and in the search for mobility 
of the fragments in the case of a suspected fracture involving a joint. 

Ecchymosis is a symptom that is rarely absent, although its appearance 
may be delayed for several days. Blood is freely poured out from the 
medullary canal and the spongy tissue of a bone, and in cases of fracture 
by indirect violence it may make its way along the muscular planes and 
first appear under the surface at a considerable distance from the seat 
of injury. Under such circumstances, its tard}^ appearance at a distance 
from a painful point upon the course of a bone, with the history of an 
injury, it raises a strong presumption of fracture, although it is by no 
means pathognomonic. In fractures by direct violence the ecchymosis 
appears promptly and at the point where the injury was received, and is 
often due as much to the contusion of the soft parts as to the fracture. 

The coexistence of an external wound is not to be lightly taken as a 
proof that the fracture is compound. The blow which has caused it 
may also have produced an indirect fracture at a considerable distance, 
or, even if the position of the fracture corresponds to that of the wound, 
the deeper soft parts may still remain undivided and prevent communi- 
cation between the two. In cases where the bone does not protrude and 
cannot be felt by cautious exploration through the wound, the diagnosis 
of a probable communication may be made if the hemorrhage is profuse, 
prolonged, and venous in character, and if it contains scattered oil-globules 
within the first twelve hours. 

In fractures communicating with joints a very notable and character- 
istic deformity is caused by the filling of the cavity of the joint with 
extravasated blood or an inflammatory effusion, the character and situa- 
tion of which are shown by its limitation within the boundaries of the 
articular capsule. 

Abnormal Mobility. — Mobility appearing after injury at a point in a 
bone where it did not previously exist, and permitting the bone to be 
lengthened, shortened, or bent at an angle, or allowing a portion of it to 
be moved while the other portion remains at rest, is pathognomonic of a 
fracture, but unfortunately it is not always present or recognizable. In 
an impacted fracture the two fragments may be so firmly wedged together 
that mobility does not exist ; and in a partial or a toothed fracture, or 
in fracture of one of two bones, as in the forearm or leg, it may be so 
slight as not to be recognizable ; and in a fracture of a short bone, or 
in one near the articular end of a long bone, one or both fragments may 
be too small to be grasped with sufficient firmness for this exploration. 
In fracture of the ribs, or sternum, or fibula, the natural elasticity or 
mobility of the bone may deceive if not taken into consideration, or 
raise a doubt if it is. 

The manipulations employed for the detection of abnormal mobility 
vary with the seat of fracture and the kind of mobility which is sought 
to be produced. In fracture of the shaft of a long bone the surgeon 
seeks first to produce an angular displacement by passing his hand under 
the limb at the supposed seat of fracture and gently raising it, or by 
grasping the two extremities of the bone firmly and moving the lower 



OBJECTIVE SIGNS. 105 

one slightly from side to side while the upper one is held stationary. 
Or* he may grasp the limb with both hands close- to the fracture, and pro- 
duce transverse displacement by moving the fragments bodily in opposite 
directions. In fracture of the shaft of the fibula a method recommended 
by Dupnytren is to place the fingers of both hands over the inner aspect 
of the limb and the thumbs against the fibula, one above, the other be- 
low, the suspected fracture ; then by making pressure alternately with 
the thumbs the independent movement of either fragment may be de 
tected. A similar manipulation can be used upon the radius or ulna. 

In fracture of the upper portion of the femur in a stout person, or of 
the neck of the humerus, or of the upper end of the tibia where a lat- 
eral or angular displacement cannot be recognized, recourse must be had 
to slight rotation of the lower portion of the limb, while the upper por- 
tion is so held that its bony prominences can be distinctly felt by the 
fingers. Abnormal mobility is recognized by the failure of the manipu- 
lation to transmit the rotatory movements to the upper fragment. The 
test is a delicate one, and it is essential that the communicated move- 
ments should be slight, for otherwise the attachments of the soft parts 
or the interlocking of the fragments may prevent the success of the ma- 
noeuvre which, moreover, for obvious reasons must fail in partial and 
impacted fractures. 

In intra-articular fracture of the lower end of the humerus or femur, 
or in fracture of an apophysis, the surgeon's aim must be to grasp each 
fragment as firmly as possible, and to move one upon the other in the 
direction of the line of fracture. 

In exceptional cases it is possible to give a fragment a tipping or see- 
saw motion ; thus, by pressing the tip of the external malleolus inward, 
when the fibula has been broken just above the ankle, the upper end of 
the lower fragment may sometimes be felt to move outward, and when 
the internal malleolus has been broken transversely a similar rocking 
movement can be given to the fragment by pressure upon its anterior and 
posterior edges. In this manoeuvre the sliding of the skin is very liable to 
be mistaken for movement of the bone, especially if the part is swollen 
and tense, and should be guarded against as far as possible by pressing 
the fingers towards each other so as to relax the skin between them. 

All these manipulations should be made cautiously, gently, and with 
close attention, and arrested as soon as the desired information is ob- 
tained, in order that the patient may not be exposed to unnecessary harm 
by rupture of remaining adhesions or by additional laceration of the soft 
parts. 

Crepitation. — This is the sound produced, or the sensation communi- 
cated to the hand of the surgeon, by the friction of broken fragments of 
bone against each other. It is as pathognomonic of fracture as is abnor- 
mal mobility, and these two symptoms usually coexist, for crepitation 
cannot be produced except by the movement of the fragments, and when 
the latter is sufficiently marked to be recognizable crepitation is rarely 
absent. 

Crepitation has been compared, for the instruction of those who have 
never felt it, to the friction or contact of various bodies, such as nuts in 
a bag, or gravel ; but these comparisons can do nothing more than con- 



106 SYMPTOMS AND DIAGNOSIS. 

vey the most general idea of the sensation, one that is little, if at all, 
more definite than that which an ordinary imagination would evolve from 
the known conditions. The simplest means of acquiring a conception of 
crepitation in default of actual practice is to break a bone or the limb of 
a dead animal and rub the fragments together with different degrees of 
force. The sensation is not the same in all cases, it runs through all the 
grades between the sharp click of two hard points or edges and the dull, 
muffled contact felt when one of the pieces, probably, is covered with 
periosteum, or the crackling and grating of comminuted fragments and 
broad surfaces. Some of its forms are practically identical with the 
friction sounds obtained by the movement of joints whose surfaces are 
altered by disease, and although it is usual to speak of a recognizable 
difference in the quality of these sensations, the one being called hard 
or rough, the other soft or smooth, the diagnosis in case of doubt must 
depend upon circumstances other than this difference. 

Crepitation is perceived rather through the hand than the ear, although 
in some cases there is a distinct sound audible to bystanders who are not 
in contact with the patient. It is to be sought by the same methods as 
abnormal mobility, and also in the ribs or flat bones by placing the palm 
of the hand over the supposed seat of fracture and pressing gently in 
different directions, or in the expectation that movements sufficient to 
produce the symptom will be communicated to the fragments by the 
respiratory efforts of the patient. Direct auscultation, with or without 
the stethoscope, is sometimes employed, but it is inferior in accuracy to 
the hand when the parts can be well grasped. It is useful in fracture of 
the ribs or sternum. Patients can usually feel the click or grating when 
the limb is handled. 

Crepitation cannot always be produced when there is a fracture. It 
is essential to its production that there should be at least two fragments 
movable at will one upon the other, and therefore its presence is con- 
ditioned, not only upon the same circumstances as that of abnormal mo- 
bility, but also upon the contact, and, in a measure, the character of the 
broken surfaces. If the fragments are completely separated by longi- 
tudinal or transverse displacement, and are not brought into contact by 
traction or pressure, if a piece of muscle or periosteum is engaged 
between them, or if sufficient time has elapsed to allow them to become 
covered with granulations, their movements will not cause crepitation, 
and it is a matter of daily experience that the same manipulation which 
produces crepitation at one moment may fail to produce it at the next. 
The reasons therefor can sometimes be observed directly in compound 
fractures of subcutaneous bones, such as the tibia, where the movements 
of the patient or the involuntary contractions of the muscles of the limb 
will be seen through the wound to change the relations of the broken 
fragments. 

The same reasons which make it undesirable to attempt a verbal de- 
scription of the sensation of crepitation apply equally to the more or less 
similar sensations produced by other conditions with which the crepita- 
tion of fracture may be confounded. The best guard against error is 
found in a knowledge of the errors to be avoided and in a careful study 
of the case with those errors borne in mind. Those other conditions are: 



SUBJECTIVE OR RATIONAL SIGNS. 107 

roughening of the articular surfaces of neighboring joints, which pro- 
duces "friction sounds" when they are moved; inflammation of the 
sheaths of tendons or of bursae, giving rise to a fine crackling when they 
are handled ; emphysema due either to the escape of air into the tissues 
from a wounded lung or to decomposition with the production of gas ; the 
crackling of coagulated blood, and a pleuritic friction sound when heard 
after an injury to -the wall of the thorax. 

Subjective or Rational Signs. 

Diminution, or total loss, of the functions of the limb or part involved 
is a common result of fracture, but as it may also be occasioned by a 
simple contusion it is not pathognomonic of the former lesion. The imme- 
diate causes of this loss of power are various : it may be due to the 
breaking of the bone between the points of attachment of the muscles 
which control it and the fixed point about which its normal movements 
take place ; or it may be due to pain excited by the slightest motion of 
the fragments or by the contraction of the bruised muscles, or to the 
paralyzing effect of the dread of pain upon the will of the patient. An 
extreme instance of the latter was recently furnished in a patient who 
came under my care for fracture of the olecranon, and in whom commu- 
nicated movements of pronation and supination were absolutely prevented 
by muscular rigidity during the first twenty-four hours, although made 
with entire freedom afterwards. The loss of function may be complete, 
as after fracture of the shaft of the femur or of the humerus, or it may 
be so slight as to be overlooked ; and the former is no more a proof of 
the severity of the injury than the latter is of its unimportance, for while 
on the one hand a severe contusion, or even the mere thought of having 
received a fracture, may prevent voluntary movements of a limb, on the 
other, patients may walk a considerable distance or raise the leg in bed 
after having broken the neck of the femur or the tibia. In a personal 
case, a man 66 years old, broke the neck of the femur by a fall clown a 
flight of stairs, he rose without assistance and walked down another 
flight before he lost control of the limb. The fracture was found at the 
autopsy to be a smooth, non-impacted, transverse fracture at the junction 
of the head and neck of the bone. Many similar cases are on record, 
and Stanley 1 has recorded a still more remarkable case of a man who 
walked four miles with the help only of a cane after his tibia and fibula 
had been broken by the kick of a horse. 

Other modifying circumstances are found in delirium, which, by ren- 
dering the patient indifferent to pain, allows him to move the broken 
limb, and in injury of a joint by dislocation or sprain which compels 
immobility. 

Pain, either spontaneous, or on pressure, or on movement of the 
limb, is a constant acompaniment of fracture, and under some circum- 
stances is a valuable aid to diagnosis, especially when the fracture has 
been caused by indirect violence or by muscular action. In suspected 
fractures by direct violence, its diagnostic value is less because the pain 

1 London Med. Gazette, 1844, vol. i. p. 273. Qnoted by Grurlt. 



108 SYMPTOMS AND DIAGNOSIS. 

may be due to injury of the soft parts, especially the periosteum, occa- 
sioned by the blow. It should be sought for by gentle pressure with 
the finger along the course of the bone, and if it is found on repeated 
examination always at the same point, and if the area within which it is 
found or is most severe is small or is distinctly circumscribed, I am in 
the habit of treating it as a sign of probable fracture when, from the 
circumstances of the case, the other and more positive signs are not to 
be certainly expected, as in some fractures at the lower end of the 
radius or of the tibia or fibula. In like manner a localized pain, excited 
by slight communicated rotatory movements of the limb at a point in the 
shaft of a long bone where there is no contusion, is a sign of probable 
fracture. Malgaigne says he has on several occasions seen a diagnosis 
of fracture made upon this symptom alone confirmed by the subsequent 
course of the case. 

The history of a case, with reference to the diagnosis, includes earlier 
injuries which may have modified the form of the limb, the nature of the 
accident and the method of fracture, and occasionally the snap heard by 
the patient or bystanders at the moment the injury was received. The 
latter is probably produced very commonly, but as a rule it passes un- 
perceived because the attention of the individual is occupied by the fall 
or the impending blow which causes the fracture. Consequently it is more 
commonly observed in fractures by muscular action than in others. As 
a similar sound may be caused by the rupture of a tendon the absence of 
this latter lesion must be established before the diagnosis of fracture can 
be made simply upon the occurrence of an audible snap at the moment 
of the accident. 

Reasons have been given already to show why it is necessary to make 
inquiries concerning previous injury to the limb, so as to avoid an error 
in diagnosis ; the danger to be avoided is that of supposing a pre-exist- 
ing deformity to have been produced by recent violence which has really 
caused only a contusion or sprain at the seat of a former injury. 

A knowledge of the mode in which the injury has been received is of 
importance in determining the diagnostic value to be attached to some of 
the symptoms previously described, especially those of pain, ecchymosis, 
and swelling ; and when, as is frequently the case, the patient is unable 
to say positively what portion of the limb received the blow, an exami- 
nation of the surface may show an abrasion or contusion or a stain left 
by contact with the ground which indicates the point in question. If a 
limited point of pain, or of greatest pain, is then found at a distance the 
existence of a fracture by indirect violence is probable, while if the pain 
is found only at the spot where the blow was received its diagnostic value 
is less. The degree of the causative violence is of less importance, in 
view both of the difficulty of correctly estimating it and of the varying 
fragility of the bones which often makes fracture possible by slight 
causes. 

These are the facts upon which a diagnosis must be based. As a gen- 
eral rule, they should all be sought for systematically, even when the 
diagnosis is not obscure, because it is only by this means that the sur- 
geon can acquire the necessary familiarity with them which will make it 
possible for him to recognize them in doubtful cases. When the surgeon 



SUBJECTIVE OR RATIONAL SIGNS. 109 

is called to a case of suspected fracture he should begin his examination 
by inquiring into all the circumstances of the injury, not only for the 
purpose of giving the patient time to recover from the excitement pro- 
duced by his arrival and the dread of a painful examination, as Prof. 
Hamilton has wisely urged, but also to obtain the information which he 
may need later when the patient is, perhaps, under the influence of an 
anaesthetic. 

In proceeding to the direct examination of the injured part, the im- 
portance of avoiding all needless pain and rough handling must be kept 
constantly in mind ;,the clothing is first removed, in doubtful cases from 
the opposite limb as well as from the injured one, and the part inspected 
for the discovery of any contusion, ecchymosis, swelling, or deformity 
recognizable by the eye. If a deformity is found its extent may be de- 
termined in suitable cases by measurement. Then the fingers are lightly 
passed along the course of the bones which may be the seat of the injury, 
in search of a painful point, or of any irregularity in outline ; if the in- 
jury is in the vicinity of a joint, the ends of the bones which form it are 
carefully explored, their relations to each other compared with those of 
the corresponding bones on the opposite side, and the functions of the 
joint examined by communicating cautious movements to it. 

Crepitation and abnormal mobility are next to be sought for by the 
methods heretofore described, and an anaesthetic employed if necessary. 

If a fracture has been detected, and if it is associated with a wound 
of the soft parts that probably makes it compound, the wound may be 
explored, preferably with the finger, for the purpose of determining the 
character of the fracture and of removing loose splinters of bone ; but 
this is an exploration that should never be lightly undertaken, and in 
making it the surgeon should feel that he may, perhaps, do the patient 
harm that will not be fully compensated for by the information he 
obtains. 



110 



REPAIR OF FRACTURES 



CHAPTER VI. 



REPAIR OF FRACTURES. 

The clinical phenomena which accompany the healing process after 
fracture of a bone vary with its character, and especially with its com- 
plications. In the simpler cases, when the injured limb has been prop- 
erly secured by splints and bandages, the patient is usually free from 
pain and fever ; he eats and sleeps well, disturbed only by the confine- 
ment to which he is subjected, and by more or less vague sensations of 
weight and uneasiness in the limb, or, perhaps, occasionally by involun- 
tary twitchings of the muscles. A few blebs may form on the surface 
of the limb, but seldom cause any uneasiness. During the forty-eight 
hours immediately following the receipt of the injury he usually shows 
some rise of temperature, but it seldom reaches any great height or lasts 
long. A number of thermometrical observations in simple fractures, un- 
accompanied by much displacement, were made by Dr. Stickler 1 and Dr. 
Root, in my services at the Presbyterian and Bellevue Hospitals, and 
showed as light rise always. The accompanying thermograph, fig. 58, 

is from one of Dr. Root's cases, 
Fig. 58. a simple fracture of the leg. 

Within a few hours after the 
receipt of the injury the limb 
swells, especially in the neigh- 
borhood of the fracture, and 
this swelling may be accom- 
panied by puffiness of the cor- 
responding hand or foot, due to 
interference with the return cir- 
culation. The swelling dimin- 
ishes in a few days, and then a 
firm, rounded mass can be felt 
about the bone at the point of 
fracture, which is tender on pressure, and, during the following weeks, 
becomes gradually smaller and harder. As this mass hardens the abnor- 
mal mobility, which may have been noticed immediately after the in- 
jury, diminishes, and finally disappears, and the union is then complete, 
although not so strong as it will subsequently become. The hard mass 
which has effected the union continues to diminish for months afterwards, 
perhaps for years, so that in the simplest cases where, for example, the 
periosteum has not been torn, no trace of it will remain ; but usually it 
can be detected after scraping the bone, or sawing it lengthwise. 



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1 N. Y. Medical Record, 1882. 



KEPAIR OF FRACTURES. 



Ill 



In the severer cases, those marked by more displacement of the frag- 
ments, shattering of the bones, and violence of the reaction, the same 
sequence of phenomena is presented, but there is more pain, more 
swelling, and more general disturbance of the system. It has also been 
recently observed by Riedel (Deutsche Zeitschrift fur Chirurgie, vol. x. 
p. 539) that in these cases and also in the less severe ones, albumen 
and casts are present in the urine during the first few days following the 
injury, and he describes in particular a kind of cast not found in the 
common diseases of the kidney, a brown granular cast of medium size. 
He attributes this intercurrent nephritis and the fever to the absorption 
of the serum of the blood extravasated and coagulated at the seat of 
fracture. He also found free fat in the urine in 42 per cent, of the 
cases examined. 

The greater the displacement of the fragments and the consequent 
laceration of the soft parts at the time of the injury, and the more acute 
the onset ot the inflammatory processes, within certain limits, the larger 
will be the mass (callus) which forms at the seat of fracture, both tem- 
porarily and permanently, and the greater the permanent deformity. 

Usually the symptoms do not long remain acute, the oedema and red- 
ness diminish, the skin assumes a yellow color for a considerable distance 
on all sides, especially towards the trunk, the bandages are found loose 
at the daily examination in consequence of the subsidence of the swelling, 
the patient loses the pain and malaise previously felt, he eats and sleeps 
well, and convalescence is fairly established. But if some cause of 
irritation persists, if the tissues are constantly subjected to fresh lacera- 
tion by the unreduced fragments kept constantly in motion by the invol- 
untary contractions of the muscles or the delirious agitation of the patient, 
the prognosis becomes less favorable because the processes of the first 
stage are then more likely to terminate in suppuration instead of resolu- 
tion. This suppuration may be confined to the seat of the fracture, the 

Fi<?. 59. 



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fcimple fracture becoming compound on the 9th day. 



112 REPAIR OF FRACTURES. 

ends of the fragments lying bare in the cavity of the abscess, or it may 
spread up the limb accompanied by sloughing of the connective tissue 
and the formation of abscesses at various points, the deadly acute puru- 
lent infiltration of the older writers. Gangrene of the skin over the 
fracture may occur during the earlier stages as the result either of the 
direct violence that caused the fracture or of the pressure of a displaced 
fragment. Finally, nervous symptoms may make their appearance, 
either as an attack of delirium tremens within the first few days or as 
tetanus at a later period. 

The progress of a case may be modified in an important manner by 
articular complications having their origin in direct communication 
between the fracture and a neighboring joint or in the extension to the 
latter of the inflammatory processes set up by the main injury. In the 
former case the symptoms pointing to the implication of the joint appear 
very promptly, the synovial sac becomes distended by .an effusion of 
synovia mixed with blood in greater or less proportions, and pain on 
motion is extreme and referred directly to the joint. The injury, espe- 
cially if the joint is a large one, is much more severe than a simple frac- 
ture and has a correspondingly greater effect upon the general condition 
of the patient; his temperature rises, his pulse quickens, and his diges- 
tion becomes disordered. The arthritis persists for several weeks, 
even under favorable circumstances, and either terminates in resolution 
after gradual abatement of the symptoms and with loss or diminution of 
the functions of the joint, due in part to changes in the relations of the 
surfaces to each other, or it goes on to suppuration and puts the life of 
the patient in peril. In some cases, as in fracture of the neck of the 
femur, union may fail entirely, and in others it may be fibrous instead 
of bony, results which, however, are not associated with any material 
change in the early clinical history of the case. 

When the arthritis is the result not of a direct implication of the joint 
in the fracture, but only of an extension to it of the inflammatory pro- 
cesses set up by the injury its course is less severe. The joint becomes 
distended by an effusion of synovia, and pain, both spontaneous and on 
motion, is felt in it, but the consequences are usually limited to the for- 
mation of adhesions and peri-articular thickening. Suppuration follows 
only in rare cases. 

In compound fractures the same series of phenomena is observed as in 
simple fractures, modified more or less by the coexistence of the wound.. 
The liability to destructive inflammatory processes, to suppuration at 
the seat of fracture, to burrowing of pus, and to the other complications 
above mentioned is much greater, but as it is sometimes possible to ob- 
tain prompt union of the wound and thus transform the fracture into a 
simple one the course may be as mild and free from complications as in 
the other class of cases. In other cases the wound remains open on the 
surface but its deeper parts unite, and thus the transformation into a 
simple fracture is again accomplished and the course is as mild as before 
with such slight modifications as are due to the coexistence of a super- 
ficial wound. If union is not obtained, if the wound suppurates, the 
suppurative process extends to and involves the bone, giving rise either 
to a mild, uncomplicated osteitis marked by moderate fever, more or less 



REPAIR OF FRACTURES. 113 

abundant suppuration, and formation of abscesses in the neighborhood, 
or to an acute osteo-myelitis ushered in by a chill, accompanied by high 
fever, and likely to terminate fatally by septicaemia or pyaemia. In the 
commoner class of cases, those in which the seat of fracture suppurates 
but in which the dangerous septicaemic complications do not appear, the 
general condition of the patient is not much affected. After the suppu- 
ration is fairly established the fever disappears so completely that any 
subsequent rise of temperature is to be regarded as an indication that 
something unusual or irregular is occurring in the wound, that drainage 
is imperfect, or that a new abscess is forming. The callus forms rapidly 
and exuberantly, the wound fills up but is slow to close, and fistulae lead- 
ing down to loose splinters or to necrosed portions of callus whose vessels 
have been obstructed by condensation of the tissue may persist indefi- 
nitely. 

Among the symptoms peculiar to this variety are the projection of the 
bone through the wound and hemorrhage. The latter may be either 
arterial or venous, primary or recurring, and so profuse as to place the 
patient's life in immediate danger. A condition of collapse or shock, 
marked by palor of the surface, small pulse, nausea, restlessness, and, 
perhaps, a sighing respiration, may either be produced by this loss of 
blood, or may be the manifestation of the injury done to the nervous 
system or the abdominal viscera by the original violence, which in these 
extreme cases is far in excess of that usually concerned in the produc- 
tion of simple fractures. This condition may be followed by reaction, 
or it may persist until death closes the scene, after a few hours. 

The period of time necessary to the repair of a fracture varies with 
the age of the individual, the bone involved, and the nature of the frac- 
ture ; and the time at which the restoration of the functions of the part 
can be pronounced complete is always remote, and often is never reached. 
Malgaigne says that bone for bone, and fracture for fracture, repair in 
children requires only half as much time as it does in adults, and that 
except for this neither age nor sex presents any differences, an opinion 
that has been accepted by subsequent writers. He also says that the 
bones of the lower limb require more time for repair than those of the 
upper limb, and the latter more than the bones of the face ; a fracture 
near the middle of the shaft unites more slowly than one at the extrem- 
ity of the bone, and a fracture with permanent displacement more slowly 
than one in which the fragments are retained in their normal relations to 
each other. Union may be delayed far beyond the usual time by excep- 
tional conditions, which will be considered in a subsequent chapter, such 
as the interposition of a portion of muscle between the fragments, or by 
constitutional affections, or occasionally under circumstances where the 
cause cannot be recognized. 

Even after firm union has taken place between the fragments, there 
remain changes in the limb, disabilities or weaknesses, whose slow dis- 
appearance prolongs the period of convalescence, or whose permanence 
renders a complete return to the condition existing before the fracture 
impossible. The limb is usually shrunken, and its muscles wasted and 
feeble ; the skin is dry and has a tendency to become congested on slight 
provocation, such as exposure to the air, or a dependent position. There 



11 -L REPAIR OF FRACTURES. 

is stiffness of the hand or foot of the broken limb, especially of the latter 
after walking ; the neighboring joints are stiff and tender in consequence 
of the prolonged immobility and of adhesions formed within them or the 
sheaths of the tendons ; and this stiffness and tenderness may persist 
until the end of life in the old and arthritic , even when the joint has not 
been directly involved in the injury. 

Anatomo-pathological JP7'ocesses. — Bone is one of those tissues whose 
cicatrices are composed of a substance closely resembling, or identical 
with, the original tissue. The ends of a broken bone become reunited 
by bone, and this new bone is formed out of materials furnished by the 
bone itself, its marrow and periosteum, and the adjoining soft parts. The 
phenomena which accompany "and are instrumental in producing this 
repair have been known more or less completely since observation and 
experiment took the place of pure speculation in medical science, but the 
diversity in the views held concerning their origin, nature, and purpose 
has been extreme, and exists, in a measure, even at the present time, 
although accurate and well-devised experimentation, aided by perfected 
means of observation, has resolved most of the problems and harmonized 
much that was contradictory. A brief account of the stages through 
which the study and teaching of the subject have passed seems desirable, 
to enable the reader more easily to fit that which is new on to that which 
is old, and to interpret and use the terms and observations of the older 
classical writers in the light of our more precise and detailed knowledge. 

The speculative theories of the ancients do not need mention beyond 
the fact that Galen's, which attributed repair to a "bone-jaice" poured 
out from the broken ends of the bones, was the one generally accepted 
at the end of the seventeenth century when direct observation and ex- 
periment upon animals were first employed, and the real study of the 
subject began. Antonio de Heyde 1 recorded, in 1684, the conclusions 
he had drawn from experiments made upon frogs ; he thought that the 
callus was formed by the solidification of the blood poured out between 
the fragments. Du Hamel, 2 experimenting upon pigeons and sheep, and 
interpreting the facts in the light of previous study of the method of re- 
pair in trees (he seems not to have been a physician, and certainly not a 
surgeon), formed the opinion that the periosteum, aided somewhat by 
the marrow, was the active agent of repair. His observations were 
numerous and accurate ; he noticed the new formation of bone under the 
periosteum for some distance from the fracture and the smoothness of 
the bone wherever the periosteum had been stripped from it ; also the 
tumefaction of the periosteum and the interposition of a thin gelatinous 
layer between it and the bone. He even placed, as all do now, the espe- 
cial osteogenetic quality only in the innermost layer of the periosteum, 
or in the gelatinous layer just mentioned which adjoins and is produced 
by it, and attributed to them the normal growth of a bone in thickness, 

1 Ex his experiments forsan probatur callum generari e sanguine evasato, cujus 
fluidis particulis sensim exhalantibus reliqnum ossis formam assumit, quod promo- 
veri potest ab lialitu ex ossis fracti extremis deciduo. Quoted by Du Hamel in His- 
toire et Memoires de l'Academie Royale des Sciences, 1741, p. 222. 

2 Hist, et Mem. de l'Acad. Royale des Sciences, 1741, pp. 97 and 222, and, 1743, pp. 
69, 87, 111, and 288. 



REPAIR OF FRACTURES. 115 

comparing it to the growth of a tree by the formation of wood under the 
bark. He denied that the cortical layer could reunite, and having in 
one case found a union so perfect that he could not trace the line of 
fracture after having sawed the bone, he boiled the specimen in a strong 
solution of lye, and had the satisfaction of seeing it fall into two pieces 
and thus confirm, as he supposed, his opinion. He claimed also that the 
lamellae of the spongy tissue and on the border of the marrow were cov- 
ered by a membrane that had its origin in, and possessed the functions of, 
the periosteum. In fact, he anticipated by one hundred years the dis- 
coveries of Syme, Heine, and Oilier, although it was left to these latter 
experimenters to furnish the actual demonstration. 

A few years later, 1748-1767, Haller, Boehmer, and Detleef opposed 
Du Hamel's views, and reasserted the former theory of the " bone- 
juice" ; according to them this juice w T as poured out by the bone, became 
gelatinous, then cartilaginous, and finally bony ; and at about the same 
time an opinion first published by Jean Louis Petit, to the effect that the 
callus is formed by granulation tissue, as a cicatrix of the soft parts is, 
was again put forward and warmly defended by Bordenhave and others. 

About a hundred years after the publication of De Heyde's experi- 
ments, his theory that the callus had its origin in the blood poured out 
between the bones at the time of the fracture, was revived by John Hun- 
ter, and thoroughly elaborated a few years 'later, with the aid of experi- 
ment and microscopical examination, by Howship, 1 whose descriptions 
are remarkably accurate and detailed, although his interpretation of the 
facts was erroneous. 

Of these theories all except the one last mentioned are partly true, 
and together they furnish the basis of all subsequent ones. They erred 
because they were too exclusive or too indefinite, but being based upon 
experiment and observation they furnished sound data for speculation, 
and indicated new lines of research, w T hich have since been freely used 
by theorizers, or followed out by investigators. The main facts, as far 
at least acs the gross appearances were concerned, were fairly before the 
profession at the beginning of the present century, and upon them and 
the pathological and clinical facts furnished by his large experience 
Dupuytren constructed his theory of the development of the callus, a 
theory complete in all details, logical in its development, seductive in its 
fulness and verisimilitude, lacking only in accuracy. As the terms and, 
in a measure, the ideas of this theory are current at the present time, 
it requires description. 

Dupuytren brought again into prominence Du Hamel's theory of the 
part played by the periosteum, a theory which had been almost lost sight 
of in the general acceptance, under the able advocacy of Bichat and 
Scarpa, of that of repair by granulations springing from the broken 
bones, and extended it by attributing the same power to the adjoining 
soft parts when the exercise of that power was necessary. He described 
two calluses, the one temporary or "provisional," the other permanent 
or " definitive." The former was composed of two parts, the volumi- 
nous ovoid mass of spongy bone that incloses and binds together the 

1 Med. Chirurg. Trans., 1818, vol. ix. p. 143. 



116 REPAIR OF FRACTURES. 

broken ends of the bone and to which the name " ensheathing callus" 
has been given by the English authors, and a central bony plug uniting 
the two portions of the medullary canal. The broken bone itself, that 
is, its compact layer, did not share, according to Dupuytren, in the pro- 
duction of this callus and had no immediate union with it; the fragments 
were simply imbedded in a mass of spongy bone produced by the joint 
action of the marrow, periosteum, connective tissue, and even the mus- 
cles themselves, which made up by its bulk for its lack of compactness 
and kept the pieces immovable until a small bond of firm, compact bone, 
the definitive callus, had formed between and restored the direct conti- 
nuity of the cylindrical shell. He divided the period of formation and 
development into five stages 1 : 1st, the stage of irritation, lasting until 
the eighth or tenth day, during which extravasations of blood take place 
between the fragments and into the adjoining tissues, the connective 
tissue swells and becomes more firmly united with the periosteum and 
muscles, the marrow thickens, and a viscid substance or a mass of pink 
granulations fills the space between the fragments ; 2d, the cartilaginous 
stage, lasting until the twentieth or twenty-fifth day, during which the 
external callus is formed from the periosteum and soft parts and is trans- 
formed into cartilage, the change beginning in the centre and extending 
outwards, and the medullary canal is closed by a bony plug formed 
within it ; 3d, the stage of spongy ossification, lasting until the fiftieth or 
sixtieth day, during which the provisional callus is completed by its 
transformation into spongy bone ; 4th, the stage of compact ossification, 
lasting until the fifth or sixth month, during which the substance between 
the fragments, which appears as an interposed line of different color, 
grows firmer and whiter and is finally changed into compact bone, estab- 
lishing firm union between them ; 5th, the stage of disappearance of the 
provisional callus, lasting until the tenth or twelfth month, during which 
the external callus and the medullary plug are absorbed. 

All subsequent theories and descriptions of the process of repair are 
modifications or amplifications of one or more of those above mentioned, 
so far as the origin and nature of the process are concerned, and owe 
their individuality to the importance given by them to one or the other 
element in the process or to the effort to establish differences based upon 
the degree and character of the displacement of the fragments. The 
discrepancies are more apparent than real, and the observed clinical differ- 
ences can all be referred to variations in one and the same fundamental 
process, variations imposed upon it by the relations of the periosteum 
and fragments to each other. 

The process of repair after fracture is fundamentally the same as that 
of repair after other injury, and its phenomena differ only in degree from 
those of normal nutrition and growth of bone. It is the normal nutri- 
tive process exaggerated by the irritation of the traumatism, and as such 
involves all the constituent parts of the bone. It begins with the multi- 
plication of the cellular elements of the periosteum, marrow, Haversian 
canals, and lacuna? of the spongy tissue ; this multiplication produces a 
mass of granulations which fill the gap between the fragments and are 

1 Leqons orales de clinique cliirurgicale, vol. ii. p. 49. 



REPAIR OF FRACTURES. 117 

transformed into bone, sometimes directly, sometimes after having passed 
through a cartilaginous stage. This mass of new bone, at first spongy 
in its structure, that is, composed of irregular lamellae or plates circum- 
scribing relatively large lacunae filled with bloodvessels and medullary 
elements, — becomes firmer and more compact in some portions by in- 
crease in thickness of the lamellae and consequent reduction in size of 
the lacunae, the process known as "condensing osteitis," a stage of pro- 
ductive osteitis, and observed constantly in the foetus as well as under 
many pathological conditions, and becomes thinner and weaker in other 
portions until it finally disappears by the converse process, diminution 
of the lamellae through their absorption by the medullary elements of the 
lacunae, "rarefying osteitis," another stage of productive or simple ostei- 
tis and also found in the normal development of a bone and in pathological 
conditions. There is nothing in the process more mysterious than this, 
nothing that requires the intervention of a special Deus ex machina, 
nothing that distinguishes it fundamentally from that of the repair of any 
other member of the great group of the connective tissues. The vari- 
ations depend upon differences in the degree of the injury or in the 
position of the fragments, which require disproportionate amounts of work 
to be done by the different parts. The details of the process will appear 
upon examination of the manner in which it is carried on after simple 
fracture of the shaft of a long bone, an example which has the advantage 
of illustrating the behavior of all the different elements and of being 
both more complete and more open to experimental study than fractures 
of short bones or of the spongy extremities of long ones. 

When a fracture takes place the cylindrical shell is broken along an 
irregular line and probably always with the production of splinters of 
greater or less size. The marrow is bruised by the pressure of the 
broken ends as they slip past or are driven into each other. The peri- 
osteum is usually torn, but the extent of its rupture has probably been 
largely overestimated even when there is much displacement of the frag- 
ments. Oilier 1 was the first to call especial attention to the preservation 
of its continuity at some part of the periphery of the bone, and to the 

Fi^. 60. 




Periosteal bridge" after fracture of a rib. 



fact that when a lateral or longitudinal displacement has occurred the 
membrane is stripped partly off one fragment, but without having its con- 
tinuity broken, and thus forms a band uniting the two fragments. To 



1 Traite de la Regeneration des Os. 



118 REPAIR OF FRACTURES. 

this band he gave the name of "periosteal bridge." Fig. 60 represents a 
periosteal bridge of this kind as I found it eight days after the fracture 
of a rib. The same rib showed at another point of fracture the perios- 
teal envelope complete except for a distance of one-fourth of an inch. 
The patient was an old man and the fractures were caused bj a fall from 
the fourth story of a house. In another case, an extensive depressed 
fracture of the skull in a lad of IT, I found the pericranium untorn but 
separated from the bone over the entire area of the depression by effused 
blood. In compound fractures with protrusion of a fragment it is com- 
mon to find the projecting end and other portions accessible to the touch 
denuded of periosteum ; and remembering also that the periosteum is 
rather loosely attached to the bone and, on the other hand, is continuous 
by an intimate structural union with the overlying soft parts, I am in- 
clined to believe that its continuity is largely preserved in all cases, or 
that if temporarily destroyed at some points by perforation by a frag- 
ment it is practically restored when the displacement is corrected. The 
observed liberty of motion is given to the fragments by the stripping up 
of the periosteum from one or both of them, and the extent of this denu- 
dation depends upon that of the displacement. This being so, the 
periosteum would furnish a tubular sheath connecting the ends of the 
fragments and all splinters except those that are entirely loose, guiding 
and limiting the formation of the new tissue that is to establish the 
ultimate union. Whether this sheath is complete or not, the existence 
of the periosteal bridge indicated by Oilier is of extreme importance 
because it maintains the connection between the fragments by means of 
a tissue whose activity in the production of bone is abundantly estab- 
lished. The position and form of the callus in numerous specimens of 
union with displacement have seemed to me to indicate clearly the posi- 
tion and agency of a periosteal bridge. 

At the same time blood is poured out from the torn vessels of the 
bone into the gap between the fragments, and from the vessels of the 
adjoining soft parts into the interstices among the muscles. This blood 
is gradually absorbed during the first few days following the receipt of 
the injury, and at the same time the effects of the traumatism are mani- 
fested in the usual inflammatory oedema of the limb and the infiltration 
of a thick viscid liquid into the soft tissues immediately adjoining the 
seat of the fracture, the beginning of the firm ovoid mass which can 
always be felt at this point. The periosteum becomes much thicker, 
softer, and more vascular, a thin layer of gelatinous or viscid liquid is 
found between it and the bone for the distance of a few lines from the 
edge of the fracture or from the point to which the membrane has been 
stripped up, and at the more distant limit of this layer the surface of 
the bone promptly becomes roughened by the formation of patches of 
new bone. The portions of the periosteum which have been stripped off, 
those which form complete or incomplete periosteal bridges, and the 
lacerated tissues which form the wall of the cavity in which the ends of 
the bone lie granulate and pour out lymph into this cavity to mingle with 
the partly coagulated blood remaining there. 

The marrow shares in this production of granulations ; and the cells 
of the connective tissue external to the periosteum share for a greater 



REPAIR OF FRACTURES 



119 



or less distance in the irritation and by their proliferation bind together 
all the adjoining parts, muscles, tendons, and fascite, in one firm, com- 
pact mass. The compact layer of bone, the cylindrical shell of the shaft, 
feels the same influence and reacts in the same manner, but much more 
slowly in consequence of the scantiness of its available cellular elements. 
Its surface and that of its broken ends soon show pink points which 
enlarge and send .out granulations to join those already produced by the 
periosteum and marrow, and thus there is formed between the separated 
fragments a bond of union which is actually continuous, almost from the 
beginning, with all their constituent parts. It has no strength, no ability 
to resist an external strain, such as is possessed by bone ; that strength 
will be given to it by ossification, but meanwhile its weakness is supple- 
mented by the inflammatory tumefaction of the neighboring parts which 
impedes the movement of the fragments, and by the enforced rest to 
which the limb is condemned by the nature of the injury. The size and 
character of this bond vary with the degree of displacement ; if the frag- 
ments remain nearly in their original relations to each other the bond is 
short and symmetrical, the granulations springing from the marrow meet 
and unite in the centre of the gap, while the thickened periosteum 
passes directly from one fragment to the other, remaining adherent to 
them or separated only by a layer of effused blood. If longitudinal and 
lateral displacement occurs and persists the bond passes obliquely from 
the outer surface of one fragment to that of the other and is much more 
complete at some points of the periphery than at others. Tnus, in 
figure 62, which represents the condition found by Gurlt on the seventh 



Fig. 61. 





Callus of a pigeon's bone on the 6th day. 
(Du Harael.) 



Tibia of rabbit, 7th day ; a. blood : b. carti- 
laginous callus; c. muscles. (Gurlt.) 



day after fracture of the tibia of a rabbit, the firmest union is by the 
cartilaginous band crossing the angle at b and formed apparently by the 
thickening of a periosteal bridge. On the opposite side of the lower frag- 
ment the beginning of an incomplete band of similar structure is seen. 



120 



REPAIR OF FRACTURES 



The formative action thus begun is rapidly carried on, and principally 
by the periosteum and marrow. When the fragments are kept end to 
end an ovoicl mass of tissue having the consistency of jelly and a pearly 
white appearance, and continuous above and below with the periosteum, 
envelops them, the so-called "ensheathing callus." This mass is formed 



Fte. 63. 




Callus oa the loch day. (Howship.) 

not solely by granulations springing from the under side of the perios- 
teum, but also by the thickening of the connective tissue on the outer 
side, including even that which surrounds the adjoining muscular bandies 
and fibres. Composed at first of embryonal elements, it soon becomes 
cartilaginous ; then lime salts are deposited at different points within it, 
and finally it is transformed into bone. 

The granulations that spring from the marrow ossify without passing 
through the cartilaginous stage, and the process here apparently begins, 
as in other pathological conditions, at the fine lamellae which lie upon the 
inner side of the compact shell. The new lamellae extend across the 
canal, soon occluding it entirely, and also out into the interval to meet 
those coming from the other fragment. Thus is formed the internal or 
medullary plug. 

The granulations lying in the annular interval between the two portions 
of the compact tissue, the "intermediate substance" which, according to 
Dupuytren, was to form the definitive callus, ossify as the rest do after 
passing through the cartilaginous stage, and become united to and con- 
tinuous with the compact tissue, but they originate in the periosteum or 
the adjoining subperiosteal layer. The lateness of this union, which 
does not become firm for several months, is due to the slight vascularity 
of the compact tissue, to the small size and limited number of the chan- 
nels in which the bloodvessels and cellular elements are contained. The 
capillaries which open upon the surface of the fracture are occluded by 
coagulation, and the cell proliferation which begins behind the clots can 
make its way to the surface and form granulations there only after 
absorption of a certain amount of the bone itself. This absorption takes 
place either along the sides of the channels (Haversian canals) leading 
directly down to the surface of the fracture, or along a line parallel to 
this surface ; in the latter case a scale of bone is separated or " exfo- 
liated," as is often seen in a compound fracture or after an amputation 
or resection. In a simple fracture such a scale, if formed, probably 
undergoes complete absorption, or perhaps may be imbedded in the callus 



REPAIR OF FRACTURES 



121 



as splinters of larger size sometimes are. The compact tissue, therefore, 
has to pass through a preliminary or preparatory stage of rarefying 
osteitis which approximates its structure to that of the spongy bone of 
the callus, so that at a certain time we find on longitudinal section through 
the two fragments and the callus that the original compact tissue on each 
side becomes gradually more and more spongy or vascular as the line of 
fracture is approached, shading off into the callus in such a manner that 
this line can scarcely be recognized. Ultimately this spongy bone is 




Callus and adjoining rarefied bone. (Howship. 



made denser by the deposit of new bone on the surfaces of the lacunae 
and the consequent diminution of the latter, and thus its structure be- 
comes more nearly identical with that of the compact tissue, although it 
never presents the same regularity and symmetry in the size and arrange- 
ment of its canals. 

Fragments of the cortical layer broken off at the time of the injury 
may remain attached to the periosteum, preserve their vitality, share in 
the same processes, and form a part, often an important one, of the 
callus. There is reason to believe also that even after they have been 
entirely detached they may form new connections with the soft parts 
and granulations, and preserve, perhaps even renew, their life. Such 
fragments have been found imbedded so deeply in a callus that no other 
explanation than that of complete detachment can well be accepted. 
Howship describes and figures one, and Gurlt another and very remark- 
able one, figure 65. Quite recently the possibility of this preservation 
has been established by experiment upon animals. Portions of the shaft 
of a long bone have been chiseled off, separated entirely from the soft 
parts, and replaced in contact with the bone ; the wound of the soft parts 
united promptly under antiseptic treatment, and subsequent examination 
after the lapse of a sufficient period of time showed reestablishment of 
vascular connection and preservation of the vitality of the fragments. 1 

' Centralblatt fur Chirurgie, 1880, No. 44. 



122 



REPAIR OF FRACTURES 



Fis:. 65. 



Bergmann presented at the 10th Congress of the German Gesellschaft 
fiir Chirurgie 1 a specimen of gunshot wound of the knee-joint in which a 
fragment of the external condyle of the femur had 
been driven into the crucial ligament and had 
healed there ; the length of time that had elapsed 
since the receipt of the injury is not given. The 
patient died of dysentery. 

It is also known that fragments may long re- 
main without vascular connection imbedded in a 
callus as well-tolerated foreign bodies. After 
the lapse of months or even years, and from 
unknown causes, they sometimes cause irritation; 
an abscess forms, the bone softens about them, 
and either they are cast out spontaneously or 
they remain, provoking an interminable suppura- 
tion, until removed by the surgeon. This is 
frequently observed after gunshot fractures. 

It occasionally happens that the callus does 
not ossify, and in some very exceptional cases 
the bone is entirely absorbed for a very consider- 
able distance on each side of the seat of fracture. 
The causes are not fully understood. The dif- 

Fis. 6Q. 



Fracture of the neck of the 
femur and of the shaft. A 
splinter, a, 5 inches long- and 
nearly 1 inch wide, composed 
of the cortical layer, has been 
turned completely about its 
long axis and become united, 
with its original periosteal 
surface in contact with the 
other fragments. (Figured by 
Gurlt from the Museum of the 
Koyal College of Surgeons, 
England, No. 454.) 





Portion of humerus removed in an operation for pseudarthrosis. 



ference in the process consists in an entire or partial absence of produc- 
tive osteitis, and in an excess of the rarefying osteitis ; the consequence 
of the former is the development of the granulations into fibrous tissue, 
with occasionally an irregular outgrowth from the end of the bone ; 
that of the latter is loss of substance of the bone itself, reducing its 
thickness or its length, and sometimes causing it to terminate in a point. 
Figure Q6 represents a portion of bone which I removed in an operation 
for pseudarthrosis of the humerus ; it shows a central cavity formed 
within the bone, a perforation near its lower edge, and a considerable 
prolongation of one angle. The end of the lower fragment was conical. 



1 Beilage zum Centralblatt fiir Chirurgie, 1881, No. 20, p. 14. 



REPAIR OF FRACTURES. 123 

In a second variety of pseudarthrosis the fibrous bond extends not as 
a solid cord between the fragments, but as a cylindrical one, similar to 
the capsule or ligaments of a joint, and the ends of the bones become 
eburnated, smooth, and rounded by friction upon each other, or covered 
by a layer of cartilage. 

The diminution of the callus and the rounding off of projecting points 
or ends, which take place slowly during the months following the injury, 
are effected by a continuation of the same process of rarefying osteitis 
w T hich begins so early and prepares the bones for union. Sir James 
Paget 1 mentions a case in which the size and prominence of the absorbed 
portion of bone made it possible to observe the process in its different 
stages. U A patient in the Exeter Hospital had a bad comminuted 
fracture of the leg, and a long spike of the tibia, including part of the 
spine, could not be reduced to its exact level, but continued sensibly ele- 
vated, though in its due direction. At the end of five weeks (union 
having taken place) the end of the spike began to soften ; at six, it was 
quite soft and flexible, like a thin cartilage ; at the conclusion of the 
seventh week it was blunt and shrunken. Six months later, the carti- 
laginous tip had disappeared, and the spike was rounded off." The term 
"cartilaginous" must be understood to refer only to the consistency of 
the tissue, for no cartilage is formed in this retrograde process. The 
granulations are formed by the multiplication of the soft cellular ele- 
ments lining the canals of the bone and develop directly into fibrous 
tissue. 

When the, fracture is compound the details of the reparative process 
are different to this extent, that the callus does not pass through the 
preliminary cartilaginous stage at any point where suppuration has oc- 
curred. The formation of the medullary plug is not affected, the granu- 
lations there being transformed directly into bone as they are in simple 
fractures ; the difference is in the external or ensheathing callus. The 
reason of this difference as shown by experiment 2 lies in the destruction 
of the periosteum by the suppurative process, in the destruction, that is, 
of the only tissue whose granulations pass through the cartilaginous 
stage in forming the callus. 

CD O 

The process is slower than after a simple fracture because the suppu- 
ration of the wound delays or prevents the formation of much of the ex- 
ternal callus and throws most of the labor upon the bone itself, which, as 
has been shown, is the least capable to perform it. It is easy to watch 
the process. The ends of the bone are seen lying bare and white in the 
wound ; a mass of pink granulations forms at the limit of the denudation 
and advances slowly across the bared surface ; the broken surface remains 
for a time quiescent, then granulations spring from it, beginning at the 
points nearest the medullary canal and spreading slowly towards the outer 
edge ; the wound gradually fills up with these granulations, the bone is 
covered in, and cicatrization follows. 

In less fortunate cases a portion of the bared bone dies and is cast off 

1 Lectures on Surgical Pathology, 3d ed., Pliila. 1871, p. 191. 

2 Rigal and Vignal, Comptes Rendus de l'Acad. des Sciences, 1880, vol. xc. p. 
1218. 



124 REPAIR OF FRACTURES. 

by the formation of a line of demarcation which can sometimes be seen at 
the edge of the granulations but which more commonly is hidden by them. 
It must not be thought that all the bare white bone seen in such a wound 
is dead, even after it has remained unchanged in appearance for several 
weeks. Its surface may indeed be dead, but, the interior is often alive 
and able to cast off the dead superficial scale without aid. The granu- 
lations that form between the living and the dead parts seem sometimes 
to dissolve and absorb the latter if they are small and thin, or, if not, to 
slowly bear them to the surface and cast them out. 

The callus thus formed is larger and more irregular than after simple 
fracture ; it remains tender and sensitive for a long time, and is covered 
by an adherent scar at the seat of the wound if the bone is superficial. 
Fragments formed at the time of the accident and remaining attached to 
the periosteum usually preserve their vitality ; if not, they become de- 
tached after a time and are found loose in the wound, or become shut 
in by the callus and prolong the suppuration indefinitely. In this latter 
case the constant irritation due to the presence of the foreign body, the 
existence of sinuses, and the burrowing of the pus interfere with the 
evolution of the callus. Instead of undergoing a gradual and uniform 
diminution and condensation it becomes eburnated at some points and en- 
tirely absorbed at others, irregular prominences appear on its surface 
or follow the lines of attached tendons and fasciae, and its interior is oc- 
cupied by cavities of various sizes usually suppurating and in communi- 
cation with the exterior. The walls of these cavities are sometimes 
carious, sometimes covered with feeble granulations that furnish a con- 
stant discharge and show no tendency to fill the cavity and ossify. 
Malgaigne extracts from the Memoires de l'Academie de Chirurgie a 
case of gunshot fracture of the femur below the trochanter, the persis- 
tent suppuration from which caused the death of the patient in five 
years. All the sinuses led into a large cavity in the bulky and irregu- 
lar callus, and this cavity was lined at all points by a thick, soft, whitish 
membrane, while the burrowing of the pus on the outside had denuded 
the great trochanter and rendered it and the hip joint carious. 

In compound fractures, accompanied by much shortening of the bone 
and laceration of the soft parts, the inevitable suppuration of the latter 
is usually so prolonged and so extensive that most of the smaller frag- 
ments cannot preserve their vitality, and their loss creates a gap often 
too large to be filled by the new bone. The granulations become fibrous 
instead of bony, and the only union between the two ends of the bone 
is by a dense band of connective tissue. 

The duration of the process of repair after a compound fracture varies 
greatly, as may be inferred from what has already been said. If the 
external wound closes without deep suppuration the course is the same 
as that of a simple fracture ; if, on the other hand, necrosed fragments 
become imprisoned in the callus the resulting fistulae persist indefinitely. 
As a general rule, however, a much longer time is required for the estab- 
lishment of firm union than after simple fracture. 

In the short and flat bones which have no medullary canal, and in the 
spongy extremities of the long ones, the details of the process of repair 
are modified only by the absence of the marrow. The same granula- 



REPAIR OF FRACTURES 



125 



tions form upon the broken surfaces of the bone, and the torn periosteum 
and soft parts unite and ossify. The external callus in the ribs is often 
large, because of the mobility of the parts, but in the other cases men- 
tioned there is usually but little projection of the callus beyond the out- 
line of the bone, probably because the displacement and laceration are 
less, and possibly, in part, because the periosteum, being more adherent 
than it is upon the shaft and more generally perforated by tendons and 
ligaments, is not stripped up to any £reat extent, but is torn directly 
through along the line of fracture. When the fragments are replaced 
the edges of the periosteum unite promptly and confine the mass of 
granulations within a narrower space than when this membrane has been 
stripped up and is held away from the bone by an interposed clot of 
blood. In short, the condition of the parts is more likely to be favor- 
able to the work, for the surfaces of contact are broad, uniform in struc- 
ture, and with a large proportion of spongy bone, from which the granu- 
lations can spring immediately without the aid of preliminary rarefaction, 
and the fragments are not liable to be disturbed by the involuntary mus- 
cular twitchings or movements of the patient. 

In fractures involving joints the form and origin of the callus are 
again modified by anatomical differences, of which the absence of peri- 
osteum and other soft tissues on the articular surface is the chief. The 
fracture communicates more or less freely with the cavity of the joint, 
and the synovia bathes the granulations and interferes with their devel- 



Fis:. 67. 



Fig. 





Bony union of the patella. (Bryant.) 



Comminuted fracture of the patella. Bony union. 
Exuberant callus at several points. (Gurlt.) 



opment, as an excess of liquid usually does. The absence of periosteum 
on the articular surface prevents the formation of an external callus on 
that side, and union takes place by granulations arising directly from 
the fractured surfaces and by an external callus at the extra-articular 
parts of the fracture. To this extent the details are the same as in re- 
pair after fracture of the spongy bones, and the differences in result are 
mainly in the completeness of the union, which is often fibrous, and 
sometimes fails. When the conditions are favorable and bony union is 
obtained the line of the fracture is always marked on the articular sur- 
face by the absence of cartilage over it, and usually by a groove. The 
fracture of the cartilage does not heal by the formation of new cartilage ; 
usually the callus is covered at this point by a firm, white layer of fibrous 



126 



REPAIR OF FRACTURES 



tissue resembling in its gross appearance the cartilage with which it is 
continuous, but not having its structure, and sometimes the bone is bare. 
In exceptional cases the callus is exuberant and grows out beyond the 
level of the cartilage, forming an irregular mass in the place of the 
usual groove. 

Failure of union, which is not rare in articular fractures, has been 
attributed exclusively, but apparently without sufficient reason, to the 
action of the synovia upon the granulations. The cause lies rather in 
the separation or the mobility of the fragments, and also, in cases where 



Fis. 69. 



Fig. 70. 




Absorption of the neck of the femur after 
intra-capsular fracture. (Gurlt.) 




Intra-articular fracture of the lower end of 
the humerus, with exuberant callus, especially 
in front. 



the fracture lies entirely within the cavity of the joint, as in intra-cap- 
sular fracture of the neck of the femur, to insufficient blood-supply, and 
to the absence of soft parts capable of forming an external callus to unite 
and steady the fragments while union is taking place between them. 
In extreme displacement, such as complete rotation of the head of the 
humerus after intra-capsular fracture of its neck, union must take place, 
if at all, between the broken surface of the lower fragment and the articu- 
lar surface of the upper rotated one, and the materials for it must be 
furnished almost exclusively by the former, since the vascular supply to 
the other is carried on only by the vessels of such portions of the syno- 
vial sac as may have preserved their attachments to it. Partial absorp- 
tion of the head, neck, and broken surface of the trochanter is common 
after fracture of the neck of the femur, and is effected by the rarefying 
process already described. 

Exuberance of the callus, both external and intermediate, is a frequent 
cause of diminution of the functions of the joint by destroying the nor- 
mal relations of the articular surfaces, by filling up normal depressions, 
and by creating abnormal prominences. These results are usually beyond 



REPAIR OF FRACTURES 



127 



the control of the surgeon, and the latter are most common in the young, 
whose power of producing bone is greatest. Occasionally the produc- 
tive process excited by the fracture extends far beyond the limits of the 
latter, and not only may the joint itself be entirely obliterated by fusion 
of the bones which constitute it, but the process may also spread to, and 
produce the same result in, neighboring joints, as in the case represented 
in fig. 70. 

Bones which lie parallel and close to each other, as those of the fore- 
arm and leg and the ribs, may become united by an exuberant callus 
when either one or both are broken. This consolidation occurs most 
frequently when both bones are broken at the same level, and when the 
displacement of one or more of the fragments diminishes the normal 
interval between them. The lacerated soft parts granulate as has been 
described, the mass of granulations developed about one fracture becomes 
continuous with that developed about the other, and ossification follows. 
The presence of an interosseous membrane favors this undesirable result, 
for this tissue has the same tendency to ossify that is shown by other 
fasciae and tendons in the presence of a productive osteitis. The effect 



Fisr. 71. 



Fig. 72. 



Fisr. 73. 




Bony ank losis of the root and ankk 
after fracture of the leg. (Gurlt.) 





Fracture of the forearm, an- 
gular displacement, and union 
between the bones. 



Fracture of the tore- 
arm, with formation of a 
lateral joint. 



of this consolidation is, of course, to prevent independent motion of the 
two bones, and while of no importance in the leg and of little, if any, 
in the ribs, it produces a very serious disability in the forearm by causing 
the loss of the movements of pronation and supination. It occasionally 



128 REPAIR OF FRACTURES. 

happens, when two bones are broken at the same level, that the calluses 
grow into contact with each other but do not unite. Their adjoining sur- 
faces are smooth and together form a sort of lateral joint, which may allow 
movement of one upon the other. In the specimen represented in fig. 
72, pronation and supination were lost, but the loss was apparently clue 
as much to the angular displacement of the bones as to the exuberant 
callus. 

Finally, separation of the fragments may lead to total failure of union, 
to fibrous union, or to insufficient union by a bony bridge. The latter 
is found in combinations of extreme longitudinal and lateral displacements, 
and differs from normal repair only in the insufficient formation or ossi- 
fication of the granulations. Fibrous union is most common in the old, 
after fractures which have not been immobilized properly or for a sufficient 
length of time, and in articular fractures with separation, of which the 
most common examples are furnished by fractures of the patella and of 

Fig. 74. 







Fracture of the olecranon ; fibrous union. (Malgaigne.) 

apophyses to which powerful muscles are attached, as the olecranon or 
the coronoid process of the ulna. The tonicity of the muscle tends to 
draw the fragment away, and the latter is so small or so situated that 
efficient measures to counteract this action cannot be employed. The 
first steps of the process of repair may take place as usual and granula- 
tions form between the fragments, but they develop into fibrous tissue 
instead of bone, apparently because the ossific influence of the fragments 
from which they arise or to which they are attached cannot exert itself 
over the entire distance. In other cases the granulations seem- to be 
furnished mainly by the soft parts, and their development is naturally 
into fibrous tissue rather than into bone. 

When the line of fracture follows that of a still existing epiphyseal 
cartilage either wholly or in part, and the fragments are not displaced, 
union takes place apparently as readily as after simple fracture, but 
nothing positive is known of the details of the process. There is reason 
to believe that the injury does not necessarily interfere with the subse- 
quent growth of the bone : the layer of cartilage may remain unossified 
and perform its functions as before ; but it is known from the results of 
experiments upon animals and from some cases of inflammatory disease 
affecting the ends of the bones, that the effect of irritation of the epi- 
physeal cartilage is sometimes to hasten its ossification and thus arrest 
the growth of the limb. This last result must certainly be produced 



REPAIR OF FRACTURES. 129 

when the epiphysis is dislocated by the fracture and is not restored to 
its place, and experience has shown the possibility of a similar arrest by 
premature ossification due to the irritation of a fracture. (See p. 51.) 

Mr. Bryant 1 mentions a case of arrest of growth of the humerus 
amounting to three and a half inches following fracture of the shaft at 
the age of eight years, which he attributes to injury of the nutrient 
artery. Gurlt quotes a case of separation of the upper epiphysis of the 
humerus which showed, on dissection three years afterwards, a false joint 
between the fragments. The head of the bone was united to the neck 
of the scapula, and the movements of the limb were free. 

1 Surgery, 3d Am. ed., p. 833. 



130 REMOTE CONSEQUENCES OF FRACTURE. 



CHAPTER VII. 

COMPLICATIONS AND REMOTE CONSEQUENCES OF FRACTURE. 

Under this title will be described the traumatic complications that 
arise more or less promptly after fracture, although not peculiar to that 
class of injuries, and the later changes observed in the form and functions 
of the injured limb after union has been obtained, its occasional sensi- 
tiveness, and irregularities in the form and evolution of the callus. 

A fractured limb is far from having regained its former appearance 
and its functions at the time when union between the fragments may first 
be said to be complete. It is shrunken, its skin dry, rough, and scaly. 
If a lower limb it swells and reddens when the patient begins to walk, 
the swelling being most marked and firm about the ankle ; its joints are 
stiff and sometimes immovable, and it is often painful after use or during 
changes in the weather. These defects persist for a longer or shorter 
time, and some of them may be permanent. 

Stiffness of the joints is observed not only in those articulations that 
have been directly involved in the fracture, but also in others at a dis- 
tance. Sufficient mention has been made of the causes of the former in 
the preceding chapter ; so far as the stiffness is due to permanent changes 
in the form of the articular surfaces and in the relations of the different 
parts of the joint to each other, changes which oppose a mechanical 
obstacle to the movements of the bones, it is practically permanent, and 
little, if any, improvement is to be expected. Occasionally the ligaments 
lengthen under forced use, or projecting surfaces of bone are in part 
absorbed, and the range of motion may thereby be slightly increased. 

The cause of the stiffness that is so generally observed in contiguous 
joints not directly involved in the fracture, has been the subject of much 
controversy, and it is probable that there are several of them. Exam- 
ination after death or after amputation of the limb, has frequently shown 
evident signs of inflammation of the joint: injection and thickening of 
the capsule, softness of the cartilage, and sometimes intra-articular bands 
of recent formation. Quite recently Gosselin and Berger 1 reported three 
autopsies which proved, they claimed, that this arthritis is due to the pas- 
sage into the joint of extra vasated blood coming from the fracture. This 
opinion was considered much too exclusive by their colleagues in the 
Society, although possibly correct in some cases. The arthritis, which 
is especially common in the knee after fracture of the leg or thigh, pre- 
sents two clinical forms ; in one it occurs immediately after the injury, 
in the other only after the lapse of a few days. The first is undoubtedly 
due in some cases to an associated sprain, in others possibly to the causes 

1 Bulletins de la Societe de Chirurgie, 1878, pp. 6 and 336. 



EEMOTE CONSEQUENCES OF FRACTURE. 131 

described by Gosselin and Berger ; the second is the result of the exten- 
sion employed to overcome or prevent shortening. Malgaigne attributed 
the stiffness in the knee to the extended position of the joint and to 
retraction of the ligamentum patellae, and fortified the opinion by refer- 
ence to the rarity of stiffness in the elbow after fracture of the shaft of 
the humerus, which is habitually treated with the forearm flexed. But 
it is undeniable that the same stiffness is found after treatment of fracture 
of the thigh in the flexed position, and is absent when the limb is immo- 
bilized in extension for other reasons than fracture, and therefore Mal- 
gaigne's explanation must be considered too exclusive. It has been 
observed in the very numerous osteotomies that have been recently done 
for the relief of genu valgum, that after division of the femur above the 
condyles the patients are usually able to move the knee freely as soon 
as the splint is removed, and this fact indicates, in my judgment, that 
the stiffness observed after accidental fracture is probably due in great 
part to an arthritis excited by a concomitant sprain. The stiffness of the 
fingers found so constantly after fracture of the radius or forearm seems 
to be due in part to the implication of the sheaths of the tendons in the 
inflammation about the injury, and it is certainly increased by the ex- 
tended position. In other cases the pain is referred, when an attempt 
is made to flex the limb, to the seat of fracture, and thus points to impli- 
cation of the fibres of the muscle .in the callus or in the inflammatory 
thickening around it. Retraction of the peri-articular tissues and liga- 
ments, the result of prolonged immobility, is also demonstrable in many 
cases. 

The stiffness is, as a rule, most marked and most persistent in the aged 
and rheumatic; it is usually temporary, but may disappear very slowly, 
or last for years. Malgaigne speaks of a case of stiffness of the knee 
following fracture of the shaft of the femur, and persisting for twenty- 
one years. 

Atrophy of the limb is found very frequently after fracture, and is usually 
slight. It is said by Gosselin 1 to be permanent and to affect not only 
the segment of the limb that has been fractured, but also that w T hich is 
above or below. In cases where a large nerve has been injured, or 
where the callus is exuberant and painful, this atrophy may be very 
marked, and is then unquestionably due to the influence of the affected 
nerves ; but in the common slighter cases the cause is not well under- 
stood. Gosselin's experiments and those of one of his students, Lejeune, 
who had also an opportunity to weigh the muscles of a man who died 
some time after having received a fracture of the thigh, showed that the 
atrophy involved the muscles themselves, and not merely the adipose 
tissue of the limb; each muscle when deprived of its fat weighed less 
than the corresponding one of the unbroken limb. Malgaigne attributed 
it to the prolonged compression by the retentive apparatus, but Gosselin 
found it equally marked in two cases of the fracture of the elbow that 
had been treated by continuous irrigation without bandages. He there- 
fore rejects compression as a cause, and also the prolonged immobility 
invoked by others, and suggests that the atrophy is due u to a change 

1 Gazette Hebdoinadaire, 1859, and Clinique Chirurgicale, 1872. 



132 REMOTE CONSEQUENCES OF FRACTURE. 

in the distribution of the nutritive materials which is a consequence of 
the process of consolidation. Not only does the fracture draw towards 
itself a greater quantity of these materials, but the callus itself, when 
once formed, and, after its completion, the hyperostosis require a greater 
proportion for their nourishment." This explanation has not been re- 
ceived favorably, and does not seem to be either sufficient or in accord 
with other allied conditions. The atrophy appears to be most marked 
after fractures involving, or in the immediate neighborhood of, joints. 
A thesis by Sabatie, 1 gives a full bibliography of the subject and dis- 
cusses the different factors, but fails to make the cause apparent. 

Obliteration of tlie large veins in the neighborhood of a fracture is 
thought to be a rather common occurrence, and to be the cause of the 
oedema which is so constantly noticed in the limb during convalescence. 
Its immediate cause lies sometimes in pressure upon, or injury to, the 
vein, by one of the fragments or splinters, and sometimes in the spread 
to it of the inflammation of the adjoining parts, which, by setting up phle- 
bitis, leads to coagulation of the blood within the vessel. Gosselin has 
suggested also, as a possible cause of this phlebitis, the passage into the 
larger veins of irritating materials coming from the inflamed marrow of 
the bone. The oedema which results and persists until the vein becomes 
free, or a sufficient collateral circulation is established, is troublesome 
and annoying, but it is rare for any serious consequence to ensue. 
Nevertheless, a few cases of fatal embolism due to the dislodgment of 
the clot have been reported, and, therefore, the possibility of this acci- 
dent should be noted. The first reported case, so far as I know, was by 
Yirchow, in 1846, in Traube's Beitrage zur experimentalen Pathologie, 
fatal pulmonary embolism after extra-capsular fracture of the neck of 
the femur. Durodie 2 collected eight other cases, in which the death oc- 
curred twice on the 22d day, and once each on the 16th, 30th, 35th, 
47th, 50th, and 57th days ; one case was a fracture of the thigh, the 
others of the leg. Mr. Southam published in the Lancet, March 1st, 
1879, the particulars of two cases of simple fracture of the leg in which 
death was caused by an embolus lodging in the pulmonary artery, as 
proved by post-mortem examination. In one, Pott's fracture, death 
took place on the 18th day, in the other, fracture of the fibula, on the 
16th day. 

The symptoms are the usual ones of pulmonary embolism ; the patient, 
without any warning, suddenly grows livid, or very pale, with great dys- 
pnoea, anxiety, and precordial distress, and dies, usually, in a few mo- 
ments. 

It is much more common to observe the occurrence of small emboli 
accompanied by more or less severe symptoms, but terminating in re- 
covery. The symptoms are sudden dyspnoea, cough, sometimes with 
bloody sputa, and the physical signs of localized consolidation of the 
lung. The risk of this accident is sufficient to make it necessary to 
avoid all active movements and all rubbing of the limb when there is 
reason to suspect the presence of a thrombus in a large vein. 

1 De l'Atrophie Musculaire Consecutive aux Fractures. These de Paris, 1878, No. 9. 

2 Etude sur les Thromboses et l'Embolie veineuse dans les Contusions et les Frac- 
tures. These de Paris, 1874. No. 326, p. 55. 



REMOTE CONSEQUENCES OF FRACTURE. 133 

Fat embolism, too, is thought to be an occasional cause of death after 
fracture, not recognized until within the last twenty years. The fat set 
free by the crushing of the marrow makes its way into the veins and 
lymphatics and lodges mainly in the capillaries of the lungs, but also in 
those of other viscera, where it is easily recognized by the aid of the 
microscope, especially if the section is prepared by staining with osmic 
acid. 

The first occasion on which this condition was recognized as the im- 
mediate cause of death after fracture was in 1864, and as the case fairly 
represents one of the clinical forms of this complication, I reproduce it 
from the account given by Flournoy. 1 A man was brought to the surgi- 
cal clinic at Konigsberg with a simple, transverse fracture of the tibia, 
caused by the kick of a horse. At first, all went well, but the next day 
he complained of great weakness, became comatose", and died 36 hours 
after the accident. The autopsy, made by Yon Recklinghausen, showed 
numerous small ecchymoses in the brain, heart, skin of the shoulder, 
bladder, conjunctiva, and retina ; hemorrhagic infiltration of the marrow 
of the tibia for an inch on each side of the fracture, and clotted blood 
between the fragments; great oedema of the lungs. The microscope re- 
vealed fat in the capillaries, small arteries, and apparently also in the 
veins throughout the body, but especially in the lungs, where the ob- 
struction caused by it was so extensive that only a very few of the capil- 
laries seemed to have remained pervious for the blood. Von Reckling- 
hausen at once attributed the death of the patient to fat embolism, and 
under his inspiration Busch 2 soon afterwards published an article upon 
the subject which shares with one of Wagner's 3 the honor of first 
establishing the causal relation between fat embolism and early death 
after fracture. 

The following three cases represent other features and illustrate the 
rapidity with which fatal embolism may occur and the occasional resem- 
blance between its symptoms and those of traumatic shock. 

1. A healthy man 32 years old 4 broke his right femur near the mid- 
dle by a fall from a scaffold late one afternoon, and was taken at once 
to the hospital where a splint and ice-bag were applied. The next day 
he was free from pain, but in the evening his temperature had risen to 
103J°, and his pulse and respiration were quickened. During the night 
his noisy breathing attracted the attention of the nurse, and he was found 
to be comatose, with deep, frequent respirations, loud, coarse rales, 
percussion-note clear and slightly tympanitic ; pulse 100, full and strong ; 
pupils contracted; face cyanotic ; reflex irritability lost. Later a few 
convulsive twitchings were observed in the arms ; profuse perspiration ; 
tracheal rales. He died thirty-eight hours after the accident. 

The autopsy showed the small arteries and capillaries of the lungs 
filled so extensively with clear liquid fat that Czerny considered it evi- 
dently the cause of death. A considerable number of similar branched 

1 L'Embolie graisseuse. These de Strasbourg, 1878. 

2 Virchow's Archiv, 1866, p. 321. 

3 Archiv der Heilkunde, 1865, vol. vi. p. 481. 

4 Czerny, Berliner klinische Wochenschrift, 1875, p. 594. 



134 COMPLICATIONS OF FRACTURE. 

fat emboli were found in the brain, corresponding usually to small ecchy- 
moses ; and some of. the vessels of the kidney, especially those of the 
glomeruli, were filled in like manner. There was also marked oedema 
of the lungs. . 

2. A man 47 years old 1 sustained a compound fracture of the right 
leg and simple fracture of five ribs on the left side by the caving in of 
an embankment. When brought to the hospital eight hours afterwards 
there was emphysema of the entire anterior surface of the left side of 
the chest ; pulse full, strong, and slow ; respiration normal. Lister dress- 
ing of the compound fracture. 

The next day he had no fever, and the wound was aseptic. At 9J 
P. M., while feeling perfectly well, he suddenly lost consciousness; 
breathing slow and snoring ; pulse 42, full and strong ; percussion note 
over the chest slightly tympanitic but otherwise normal ; respiration 
harsh. He died one and a half hours afterwards, thirty hours after the 
accident. 

The lungs were found hypergemic and slightly cedematous, with nume- 
rous punctiform ecchymoses under the pleura and in their substance, 
and very extensive plugging of their capillaries and arterioles with fat. 
Many of the alveoli were more or less completely filled with large, round, 
fatty cells, and others contained masses of red blood-corpuscles entangled 
in fibrin. Subperitoneal hemorrhage, liver fatty, spleen and kidneys 
normal except for some fat in the vessels of the glomeruli of the latter, 
no lesion in the brain. 

3. A lad 19 years old 2 was run over by a heavy wagon and received 
compound fractures of the right thigh and leg, and a simple fracture 
of the left thigh. He lost much blood from the torn arteries of the leg, 
and was brought to the hospital at 4 P. M. in a condition of extreme 
collapse ; pulse 100 and small ; respirations not quickened ; foot cold 
and insensitive. The thigh, was amputated through the upper third. 
At 10 P. M. the breathing became rapid, without fever, and the patient 
died with increasing dyspnoea and tracheal rales an hour and a half after 
midnight. The lungs showed numerous ecclrymoses scattered through 
their substance, with extreme fat embolism ; the liver was pale ; the 
spleen firm and full of blood ; fat was found in all the glomeruli of the 
kidneys. 

It is probable that fat embolism occurs to a greater or less extent in 
all fractures, for its occurrence seems to require only the bruising of 
the marrow, the laceration of small vessels, and the existence of a cer- 
tain amount of pressure to force the liberated fat into the open capilla- 
ries or veins. All these conditions are present in fracture, and the 
capillaries of bone are particularly fit for this absorption because they 
are inclosed in bony walls which protect them from lateral pressure. 
It follows, therefore, and the conclusion is borne out by experiment, 
that fat embolism is not necessarily dangerous. So far as can be infer- 
red from the post-mortem examinations in some cases of death by an in- 
tercurrent cause after fracture and from the results of experiment, fat 

• Riedel, Deutsche Zeitsclirift fur Clrirurgie, 1877, vol. viii. p. 572. 
2 Idem, p. 575. 



COMPLICATIONS OF FRACTURE. 135 

emboli may disappear entirely from the lungs within three weeks after 
their formation, leaving behind them no recognizable traces of their 
presence and having given rise to no inflammatory lesions. The cases 
quoted above are all examples of death by obstruction of the pulmonary 
circulation within a few hours after the injury, but there are other cases 
in which death took place at a much later period, on the 6th, 8th, 10th, 
and 11th days, as the result apparently of the ecchymoses and the in- 
flammatory processes set up in the lungs and brain by the emboli. The 
following case from Riedel's paper is an example : — 

A man, 41 years old, of alcoholic habits, was brought to the hospital 
three days after he had received a comminuted fracture of the neck of 
the femur and the great trochanter. The following day he developed 
delirium tremens and jaundice, which persisted until his death two days 
afterwards. At the last he was somnolent, with a small rapid pulse. 
The autopsy showed ecchymoses in the heart under the pericardium and 
in the lungs under the pleura, oelema of the lungs, partial consolidation 
of both lower lobes, and extensive fat embolism ; the glomeruli of the 
kidneys, and the afferent and efferent vessels completely filled with fat. 

These facts, the numerous ecchymoses in many organs, and the devel- 
opment of localized pneumonia in the cases that survived a few days, are 
thought to indicate that the graver prognosis of severe fractures in the 
old and the alcoholic is due, in part at least, to fat embolism. Their 
hearts are weak, less able to force the fat through the capillaries, and 
their lungs, brains, and kidneys are less able to withstand the local trau- 
matisms or the altered conditions of nutrition produced by the plugging 
of the vessels ; and it is not without reason that some of the writers 
upon this subject have suggested that the dreaded "hypostatic" pneu- 
monia may depend quite as much upon this complication as upon the de- 
cubitus which has heretofore been considered its efficient cause, and 
that delirium tremens or nervosum may also be a secondary effect. It 
is only proper to add that a recent writer upon the subject, Wiener, 1 con- 
siders fat emboli as without influence in producing secondary effects, an 
opinion which is shared by Dr. Peabody, the accomplished pathologist 
of the New York Hospital. 

The symptoms in the acute and rapidly fatal forms resemble those of 
shock, and Czerny suggests that many deaths heretofore attributed to 
shock, traumatic delirium, or even contusion of the brain were really due 
to fat embolism. The differential diagnosis is here to be made, accord- 
ing to the same surgeon, by the intercurrence between the accident and 
the appearance of the symptoms of a period during which the patient 
seems to be doing well. The symptoms are varied and not very distinc- 
tive. The first one may be a sudden attack of extreme dyspnoea followed 
by oedema of the lungs, or a feeling of weakness without dyspnoea but 
with coarse rales, cyanosis, and a quick feeble pulse, or delirium, or 
coma. The constant signs, those upon which the diagnosis must be 
made, if at all, are those of disturbance of the pulmonary, and later of 
the general, circulation, occurring in the first day or two, and accompa- 
nied by a rapid change for the worse in the patient's condition. Exami- 

1 Wesen imd Scliicksal der Fett-Enibolie, Leipzig, 1879. 



136 COMPLICATIONS OF FRACTURE. 

nation of the urine, especially of that passed on the morning after the 
receipt of the injury, may disclose the presence in it of a few drops of 
fat. 

The only treatment to be attempted is that directed to the vital indi- 
cation, the relief of the pulmonary oedema. We are unable to remove 
the fat from the capillaries when it has once lodged in them, and our 
efforts must, therefore, be directed mainly to prevention. The broken 
limb must be kept quiet, in order that the laceration of the marrow and 
the extravasation of blood may not be increased; and as the embolism 
occurs promptly, amputation, whenever necessary, should be performed 
with the least possible delay. 

There are a number of other complications, not peculiar to fractures, 
but occurring also after other injuries, most of which are of great gravity 
and make their appearance, if at all, soon after the accident. It seems 
appropriate to consider them briefly here, before taking up the later 
complications which find their sole cause in the injury to the bone. 
They are: extravasation of blood, including traumatic aneurism and 
hemorrhage, emphysema, septicaemia, gangrene, pyaemia, tetanus, and 
delirium. 

Extravasation of blood takes place in every fracture, and even when 
quite extensive is usually without importance and requires no treatment. 
But when the blood escapes in large quantities in consequence of severe 
crushing of the soft parts or of the rupture of a large vein or artery it 
may endanger the patient's life, or render necessary the amputation of the 
limb. 

Extravasations of exceptional size may form under the fascia, or be- 
tween it and the skin. In the latter case they are commonly due to the 
action of a sliding force which has torn the skin away from the fascia 
and ruptured a large number of the small perforating veins, and, perhaps, 
some of the large cutaneous ones ; the blood may pass along the limb to 
a considerable distance, discoloring the integument, or it may collect as 
a distinctly circumscribed fluctuating swelling, or the blood may come 
from deeper sources, the fracture itself, and especially the muscles torn 
by the displaced fragments or crushed by the original violence. In 
simple fractures the source of the bleeding is usually in doubt, and under 
such circumstances no active treatment of this symptom is necessary 
beyond a moderate elastic compression of the parts to prevent further 
extravasation and favor absorption. Serious questions associated with 
the symptoms may arise if the original cause of the extravasation is a 
severe and extensive contusion of the limb or injury to the main artery, 
such as the necessity for amputation, in the former, and for formal ope- 
rations upon the wounded vessel in the latter. 

An extravasation may, by the slowness of its absorption, prolong the 
period of convalescence, for the coagulation of a large quantity of blood 
may leave a hard clot which will provoke suppuration. In some cases 
it is desirable to remove the fluid blood or the serum left after coagu- 
lation by the aspirator, but this should not be done in recent cases; and 
if suppuration occurs, or is impending, the collection must be treated as 
an abscess and opened freely. Usually, before this extreme measure 
becomes necessary, the process of repair will have advanced sufficiently 



COMPLICATIONS OF FRACTURE. 137 

to protect the patient from the especial dangers of a compound fracture, 
and the broken ends of the bones will be covered with granulations, or 
imbedded in a well advanced callus. 

Hemorrhage from a compound fracture is often severe, and sometimes 
dangerous, although it is rare that a large vessel is wounded. The 
blood comes usually from the broken bone and lacerated muscles, and 
can be arrested by cold, position, and pressure, and even when a large 
vein has been torn the arrest of the bleeding is seldom difficult ; if pres- 
sure applied methodically at the wound is not sufficient, digital pressure 
over the main artery of the limb will usually enable a clot to form 
promptly. The tourniquet should not be used, because it compresses 
the vein also and thereby favors infiltration of blood and increases the 
probability of gangrene. 

Injury of a large artery is a dangerous complication. It seldom 
happens in an ordinary fracture, except at those points where the artery 
lies very close to the bone, as in the leg. The vessel may be torn across 
by a displaced fragment, or perforated by a splinter, or so bruised or 
pressed upon that its wall sloughs, or it may be opened by the extension 
of the suppuration accompanying necrosis. When the fracture is com- 
pound the profuseness and arterial character of the hemorrhage usually 
leave no doubt as to the nature of the accident, but in simple fractures 
it is not so easily recognized at first. The blood infiltrates the tissues 
of the limb and forms a distinct, fluctuating swelling, at first without 
pulsation or bruit, but at a later period, w r hen a sac has formed by con- 
densation of the parts around it> presenting one or both, a condition 
known as traumatic aneurism, primitive false, or diffuse aneurism, or 
ruptured artery, and usually to be treated according to the principles 
established for that lesion. It has been observed, however, that a 
pulsating tumor formed promptly after fracture will sometimes disappear 
under the moderate pressure of a simple roller bandage ; two such cases 
were reported to the New York Surgical Society in 1879, and Cruveil- 
hier, who had observed the fact several times, found a possible explana- 
tion in a pathological specimen which showed that the rupture of even a 
small artery might give rise to a collection of blood so large as to raise 
the suspicion of injury to the principal artery of the limb. The diagnosis 
may be aided by the presence or absence of pulsation in the distal 
branches of the artery. Verneuil 1 reported a case cured by digital 
pressure upon the main artery, and refers to an oral communication 
from Broca that several cases had been cured by non-operative measures. 

Dupuytren, 2 who was the first to write upon this subject, collected six 
cases of rupture of an artery due to fracture, one of them associated with 
an external wound and frequent hemorrhages. Gurli 3 collected twenty- 
five cases of aneurism and arterial hemorrhage, including Dupuytren's 
list ; and more recently Laurent 4 has reported in full twenty-six cases of 
aneurism, including some of Gurlt's and rejecting others for reasons 

1 Bulletins de la Societe de Chirurgie, 30th March, 1859, vol. ix. p. 402. 

2 Lecons Orales de Clinique Chirur., 2d ed., vol. ii. p. 507, 18b9; being the sub- 
stance of a paper read before the Acad, des Sciences, 24th April, 1825. 

3 Loc. cit., vol. i. p. 526. 

4 Des Anevrysmes compliquant les Fractures. These de Paris, 1874. 



138 COMPLICATIONS OF FRACTURE. 

which do not appear. Of these, 16 followed fracture of the leg, 5 of 
the arm, 2 of the thigh, and 1 each of the forearm, carpus, and a rib. 
Of Gurlt's 25 cases 4 were in the thigh, 20 in the leg, and 1 in the fore- 
arm; 11 were "false traumatic aneurisms," 3 after fracture of the thigh, 
8 of the leg ; and 14 were cases of arterial hemorrhage, most of them 
accompanied by extensive infiltration, and 1 of them (leg) followed by 
the formation of an aneurism. Nepveu 1 collected 53 cases of injury to 
the vessels in fracture of the leg, which he classifies as follows: — 

{ External hemorrhage 14 

Primary accidents, j Collection of blood 2 

20 cases. j Infiltration of blood 1 

[Immediate diffuse aneurism 3 

t . ■ , , ( Consecutive false aneurism 11 

™L!!! ' \ Secondary hemorrhage . 15 

( Gangrene 3 



30 cases. 



The statistics of the treatment employed would be valueless without 
the details of the cases, for in most, of them it was based upon principles 
that have now been abandoned or greatly modified. Mr. Holmes 2 refers 
to " the decided tendency to recovery manifested by wounds of healthy 
arteries when uncomplicated by external injury," and adds : " It seems 
abundantly clear, therefore, that surgical interference in these cases can 
only be justified by the presence of alarming symptoms ; and that by the 
aid of simple position, and, perhaps, in appropriate cases light and even 
compression, a great number of arteries wounded in fracture will heal." 
If an aneurism forms promptly after a simple fracture, it should be 
treated by ligation or compression of the main artery above ; if it forms 
slowly and is not cured by pressure, it may be proper to wait until con- 
solidation of the fracture is well advanced, as also when it is formed at 
a late period by ulceration of the artery, and then to lay it open and tie 
the vessel above and below the opening in it ; this failing, the trunk of 
the artery must be tied above, or the limb amputated. Agnevv 3 says 
amputation is imperative in compound fractures of the thigh complicated 
by laceration of the femoral artery, and in similar injuries of the leg in 
which both tibial arteries are torn. 

Emphysema. — The emphysema which consists in the infiltration of 
atmospheric air through the meshes of the subcutaneous tissue is ob- 
served most commonly after fracture of the ribs complicated by wound 
of the lung, and after fracture of the bones of the face communicating 
with the air-passages, but also occasionally, and to a very limited degree, 
about the wound of a recent compound fracture of a limb. In the first 
case, it is due to the escape of the inspired air through the wound of the 
lung, and its passage, into the wall of the chest under the influence of 
the movements of expiration through the gap created by the fracture. 
It is seldom of any importance, although cases are mentioned in which 
it has spread over most of the surface of the body. If necessary, the 

1 Bull, de la Societe de Chirnrgie, 1875, p. 365. 

2 Syst. of Surgery, Am. ed., vol. ii. p. 384. 

3 The Priucip. and Pract. of Surgery, vol. i. p. 742, 1878. 



COMPLICATIONS OF FRACTURE. 139 

air may be let out through a trocar introduced through the skin at one 
or more points, but it usually undergoes prompt spontaneous absorption. 

The other variety, the emphysema found about a recent wound with 
or without fracture, raises much more serious questions. First described 
by Velpeau, it was attributed by him to the sucking in of the air through 
the wound by the contraction of the muscles, or the movements of the 
segments of the broken limb. It is unquestionable that this may some- 
times be its origin, but it is equally certain that it is much more often 
due to commencing gangrene or acute septicaemia, and the importance of 
the first is as nothing in comparison with the extreme gravity of the 
second, unless it may possibly be regarded as one of the latter, by serv- 
ing to introduce germs capable of exciting putrefaction. The air that 
passes through the lungs into the tissues of the chest-wall is filtered of 
all organic matter in its course through the air-passages, and is thereby 
rendered incapable of producing this effect. As the emphysema of 
gangrene is only a symptom of that complication, and as the process can 
originate without the aid of an external wound, it will be more properly 
spoken of in that connection in the following section. 

Grangrenous Septicemia. (Bronzed erysipelas; acute purulent oede- 
ma ; grave spontaneous emphysema.) — This diversity in the names given 
by different authors to this extremely dangerous complication, not of 
fractures only, but also of many other wounds, is due, not to a corre- 
sponding variety in its symptoms and course, but to different views of 
its nature, or of the importance attributed to different symptoms. I 
prefer the term gangrenous septicemia, because it expresses both the 
general and local conditions, the acute constitutional poisoning which 
kills the patient, and the local change which accompanies and, perhaps, 
causes it. The name bronzed erysipelas given by Velpeau graphically 
indicates the symptoms presented by the skin, but involves a question- 
able etiology; acute purulent oedema and grave emphysema express only 
a single symptom each, the former that of the serous or sero-purulent 
infiltration of the tissues, the latter that of the putrefaction of the same 
liquid. 

The complication is especially common in wounds accompanied by 
much contusion or laceration of the surrounding parts, but may occur 
even when there is no external wound. It begins promptly after the 
accident, usually within a few hours, always within a few days, with a 
swelling about the wound and a change in the color of the corresponding 
skin to a dark hue at the points nearest the wound, and a brow T n or 
brownish-yellow one at the outer border, or over the greater portion of 
the swelling if the latter advances rapidly. The fingers pressed lightly 
upon the surface recognize a fine crepitation due to the presence of gas 
beneath, and the wound, if there be one, discharges a thin, reddish- 
brown liquid of an extremely fetid odor, and containing a few bubbles of 
the same gas, and sometimes pus. If suppuration has fairly begun 
before the occurrence of the complication the flow of pus diminishes, 
giving place more or less completely to the thin liquid mentioned. The 
skin adjoining the wound soon becomes black and gangrenous, and this 
gangrene extends rapidly or may even appear at distant, isolated points. 
The temperature rises, sometimes with a chill, and the pulse quickens ; 



140 COMPLICATIONS OF FRACTURE. 

the patient is conscious, but dull and with an anxious expression, at first, 
and soon becomes unconscious or delirious ; the face is drawn, the eyes 
haggard, the skin and conjunctiva yellow, and death usually occurs on 
the second or third day, with all the symptoms of an overwhelming con- 
stitutional poisoning. If incisions are made in the affected skin they 
give issue to a serum similar to that furnished by the wound, and, if 
carried through the deep fascia, the muscles protrude through them in 
consequence of the tension to which they are subjected. 

The cause of this most grave affection is not entirely understood, but 
its occurrence is certainly favored by the coexistence of an open wound 
in contact with the air, a fact which points to the introduction of the 
poison from without. It is favored also by crushing of the soft parts 
and injury to the nerves, and as it occasionally develops when there is 
no external wound, it seems possible that its cause may sometimes lie in 
altered conditions of nutrition or vitality. 

The common association with an external wound and the success of 
the antiseptic method in the treatment of wounds in general impose upon 
surgeons the obligation to employ this method rigorously in all cases in 
which this complication seems at all likely to ensue, for it is only by 
prevention that we can hope to be of service to the patient. When the 
disease has appeared there is but little chance of saving the limb, or 
even the life. Incisions into the affected parts are worse than useless 
unless they can be combined with the permanent antiseptic bath, for the 
limb is saturated with the liquid, and it is fruitless to try to drain it 
away, and the incisions only furnish additional opportunities for the 
entrance of the poison into the system. Immediate amputation well 
above the affected region offers the only chance, and that but a slender 
one, of saving the patient's life. 

Grangrene. — Excluding the form just described and limiting our atten- 
tion to those due to mechanical causes acting directly upon the tissues 
that become gangrenous, or indirectly through the arteries and veins 
which carry on their blood-supply, we have to consider local gangrene 
limited, at least at first, to the region of the fracture, and total gangrene 
of a larger or smaller segment of the limb. The former is produced in 
fractures by direct violence by the simultaneous crushing of the skin and 
the tissues lying between it and the bone ; in fractures by indirect vio- 
lence it may be produced by the pressure from within outwards of an 
unreduced fragment, or by the compression of the skin between such a 
fragment and the dressings. The latter form is due to the partial or 
complete arrest of the circulation through the principal arteries and 
veins of the limb by changes effected in them by the original causative 
violence (rupture, bruising, perforation), or by their compression against 
the edge of a projecting fragment or under an improperly applied splint. 
The gangrene may be moist or dry ; the latter is due to deficient afflux 
of blood coinciding with a free return circulation, is less likely to spread, 
and is less dangerous to the life of the patient; the former is the more 
common, is frequently associated with obstruction of the venous current, 
and is more likely than the other to spread and give rise to septic 
poisoning. 

As this complication leads not infrequently to suits for malpractice, it 



COMPLICATIONS OF FRACTURE. 141 

is important to know that it is often due to causes beyond the control of 
the surgeon, such as the associated contusion, the pressure of extrava- 
sated blood, injury of the main vessels or nerves, and the occlusion of an 
artery by the pressure of an irreducible fragment. The following two 
cases will serve as illustrations of the last two causes. Many similar 
ones have been recorded. 

1. The wheel of a heavily laden wagon passed across the middle of 
the patient's arm, fracturing the humerus, but leaving no notable exter- 
nal traces. The radial pulse could be felt the next day, and the hand 
could be moved. On the following day sensibility, functions, and circu- 
lation had ceased in the forearm. The limb was amputated above the 
fracture, and its examination showed the brachial artery filled by a firm 
clot at the point corresponding to the passage of the wheel, and for a 
distance equal to its breadth. 1 

2. A lad, seventeen years old, had his femur broken just above the 
knee by the fall of a bale of goods. On the fifth day " the whole foot 
and leg to within three inches of the knee were in a state of complete 
mortification, the parts being tumid, crepitous when pressed, covered 
with dark vesications, cold, and completely insensible." The limb was 
immediately amputated just above the fracture, and its dissection showed 
a perfectly transverse fracture two and a half inches above the loAver 
end of the femur, with the upper fragment dislocated behind the lower 
one, and overriding it three-quarters of an inch. The femoral artery 
and vein were " thrust backward, and tensely drawn across the sharp 
posterior margin of the superior fragment in such a manner that it was 
perfectly obvious that the circulation in both vessels must have been 
completely interrupted." 2 

The young, women, and the old are more exposed to gangrene than 
adult males, and therefore splints and bandages must be used upon them 
with caution, and their effects closely watched. In the old, gangrene is 
more likely to be the result of a contusion than of pressure alone, for 
their atheromatous arteries are easily injured and torn. 

The symptoms vary with the extent and character of the morbid 
process. Localized gangrene caused by the pressure of an unreduced 
fragment may present no symptoms beyond the change in the. portion of 
skin involved, and a slight rise of temperature coinciding with the estab- 
lishment of suppuration and of a communication between the seat of 
fracture and the air ; and gangrene due to arterial obstruction may be 
dry in character, and marked only by the shriveling and blackening of 
the distal portion of the limb. But it is much more common to meet 
with symptoms resembling those of the second case mentioned above ; 
the limb becomes swollen, dark, insensitive, and cold ; bullae containing 
a dark-colored serum appear on the surface, and the edge of the discolora- 
tion is marked by an inflammatory zone, which may in turn become gan- 
grenous, or may suppurate and form the so-called line of demarcation. 
The effect upon the patient's general condition presents all the grada- 

1 Stromeyer, Maximen der Kreigsheilkunst, 1855, p. 92. Quoted by Grurlt, loc. 
cit., i. p. 563. 

2 N. R. Smith., Am. Jouru. Med. Sciences, 1838, vol. xxiii. p. Qti. 



142 COMPLICATIONS OF FRACTURE. 

tions between a slight one and a very severe one resembling that of 
gangrenous septicaemia. 

The treatment, in like manner, varies with the severity of the affec- 
tion. In the circumscribed cases local measures, intended to hasten the 
separation of the slough and to control its putrefaction, are sufficient ; 
when an entire segment of the limb is involved and the process tends to 
self-limitation, to the formation of a line of demarcation, it is well to 
wait until the latter is clearly defined and then to amputate ; but when 
the gangrene is spreading, and a general infection threatens, recourse 
must be had to immediate amputation above the seat of injury. Delay, 
even for a few hours, is dangerous, and the surgeon must have the cour- 
age to urge the immediate sacrifice of the doomed limb as the only 
means of saving the imperiled life. 

Suppuration (simple or phlegmonous); Pywmia ; Necrosis. — Sup- 
puration about a simple fracture is rare, except when due to contusion of 
the overlying soft parts, or to the pressure of a projecting fragment. I 
have met with no instance of it, except after fractures involving joints, 1 
but it is spoken of by most writers as a possible complication of frac- 
ture in weakly patients. The abscess formed by it leads necessarily to 
the transformation of the fracture into a compound one, either by its 
spontaneous opening or by the intervention of the surgeon. 

Acute osteo-myelitis after simple fracture is so rare that it is not 
usually mentioned in the text-books. Spillmann 2 reports a noteworthy case 
that occurred in his own practice. The patient had received a fracture 
of the lower third of the leg, not communicating with the joint, by a 
fall from a height of five feet. When first seen, thirty-six hours after 
the accident, the limb was enormously swollen, very painful, and fluc- 
tuating. Incisions carried through the skin and fascia gave exit to a 
large quantity of pus mixed with drops of fat. The patient died during 
the following night. 

In a case of separation of the upper epiphysis of the humerus quoted 
above (page 52) from Esmarch, suppuration followed, apparently in con- 
sequence of an error in diagnosis which led to two attempts to reduce a 
supposed dislocation. 

Suppuration about a compound fracture, in which primary union of 
the divided soft parts has not been obtained, is almost invariably asso- 
ciated with more or less burrowing of the pus, sometimes with grave 
phlegmonous inflammation of the limb, and occasionally with pyaemia or 
necrosis. These grave accidents, which were frequent and fatal for- 

1 Unless the following case is one : A lad, nine years old, was brought to me with 
the history that nine weeks previously he had fallen heavily upon the left side of his 
chest while skating. No symptoms were noticed at first ; on the third day a hard 
lump formed at the seat of the blow, on the seventh rib a little external to the 
mammary line, and he became feverish and delirious. He was treated first with 
poultices, then with cold, and again with poultices. In six weeks the lump, which 
had been hard, but not very painful or red, opened and discharged pus. The probe 
touched bare bone. I made an incision and removed three necrosed irregular portions 
of bone, one of them being one and a quarter inches long, and having the breadth and 
thickness of the rib. The patient showed no signs of constitutional vice, and the 
history of the case points to suppuration originating, not in a contusion of the soft 
parts, but in the fracture itself. 

2 Diet. Encyclopedique des Sciences Med., 4th series, vol. iv. p. 156. 



COMPLICATION'S OF FRACTURE. 143 

merly, have become rare under antiseptic treatment, and even in hos- 
pitals where ten years ago more than one-fourth of the compound frac- 
tures terminated fatally by pyaemia, this complication is now entirely 
absent for months together. This relative immunity is due to the pre- 
vention of putrefaction and to the thorough drainage of the wound which 
now forms so important a feature of treatment. 

The symptoms of unhealthy or excessive inflammation after compound 
fracture are in general terms as follows : At an earlier or later period 
after the receipt of the injury, usually within the first few days, the 
edges of the wound become swollen, the adjoining skin tense and red, 
the discharge, perhaps, fetid, the patient feverish and uneasy. The 
conditions are aggravated during the following days, the swelling and 
redness extend up the limb, and the surgeon finds points of greater ten- 
derness and hardness, pressure upon which causes pus to flow from the 
wound ; a chill occurs, and the temperature rises to 103° or 104°, the 
tongue becomes dry, the patient is unable to sleep without an opiate, 
and is slightly delirious at times ; the temperature falls in the morning 
and rises in the afternoon, with a regularity that is one of the character- 
istics of hectic fever ; chills occurring at intervals announce the forma- 
tion of metastatic abscesses in the viscera or joints ; pyaemia is established, 
and the patient dies exhausted in a few days or weeks. Meanwhile the 
work of repair seems to be arrested at the wound ; the discharge is pro- 
fuse, thin, reddish, and offensive, and the bone may be seen lying white 
and bare at the bottom of the cavity. 

The treatment will be given in detail in the following chapter. It is 
addressed to the purification and drainage of the wound by the free use 
of antiseptics and by counter-openings at dependent points, to the evacu- 
ation of adjoining abscesses, to the control of the inflammation by poul- 
tices, cold, hot water, irrigation, or baths, and the support of the patient's 
strength by food, stimulants, and medicine. 

Necrosis of splinters has been spoken of in the chapter on repair. 
Necrosis of a portion of one of the principal fragments may occur in a 
compound fracture as the result of the stripping off of the periosteum, 
and of the destruction of the corresponding portion of the marrow by 
crushing or sloughing. The compact tissue being thus deprived of its 
blood-supply by the rupture of the vessels which come to it from the peri- 
osteum and the destruction of those coming from the marrow, dies, and 
is slowly separated from the portion that remains alive by the formation 
of a line of demarcation at their junction, as shown in fig. 75. The 
dead piece may lie loose in the cavity of the wound, or may be envel- 
oped more or less completely by the callus, which is continuous with the 
lining portion of the shaft through new bone formed on the under side of 
the loosened periosteum (fig. 76). A few cases are on record in which 
a long piece, 6J and 7 inches in two cases, comprising the entire thick- 
ness of the shaft, had died and been removed after some weeks by the 
surgeon. 

The small pieces of bone which are so frequently cast off during the 
healing of a compound fracture are composed sometimes of splinters and 
sometimes of portions of the callus which have died in consequence of 
the excessive activity of the productive osteitis. The continued deposi- 



144 



COMPLICATIONS OF FRACTURE. 



tion of bone narrows the canaiiculi until they become no longer pervious, 
and the part dies through lack of blood. It is an irregular and objection- 
able manifestation of the effort made by nature to remove an excessive 
and unnecessary amount of tissue. 



Fig. 75. 



Fis. 71 





Necrosis of the end of a long fragment 
after prolonged suppuration. 



Necrosis after fracture of the shaft of the 
femur, with enveloping callus, a. Tin 
sequestrum. (Gurlt.) 



The presence of a necrosed fragment is shown by the persistence of a 
sinus, at the bottom of which a bare and sometimes movable piece of 
bone can be felt with the probe. The treatment consists in the enlarge- 
ment of the opening by the knife or compressed sponge, and the removal 
of the fragment. If necessary, the involucrum or the obstructing por- 
tion of the callus must be cut away. Sometimes the wound closes and 
the fragment makes its presence known only after the lapse of months 
or years. 

Muscular Twitchings and Tetanus. — Involuntary twitchings of the 
muscles of the injured limb are not uncommon in the first week follow- 
ing the injury. They are most likely to occur at night, just as the 
patient falls asleep, and cause pain by the movements they communicate 
to the broken bones. Sometimes the pain is not so disturbing to the 
patient as the feeling of indefinite* dread which may accompany the 
twitchings, and in this respect, as in others, they resemble the similar 
phenomena observed after amputations and excisions. They are relieved 
or prevented by solid support of the limb, reduction of displacement, and 
a well-adjusted splint or immovable dressing. They rarely continue 
beyond the first week, but in a few cases have merged gradually into 
tetanus. 



COMPLICATIONS OF FRACTURE. 145 

Tetanus is not a common complication of fracture. Poland 1 found that 
in thirty-two years, 1825 to 1857, at Guy's Hospital it had occurred 
sixteen times after compound and once after simple fracture, and it is 
worthy of note that seven of these cases were lacerations and fractures 
of the fingers or hands, and one of the toes. The statistics of Lawrie 
and Peat quoted by Gurlt (loc. cit., p. 554) give four cases after simple 
fracture and seven' after compound ; while of twenty reported cases col- 
lected by Poland and analyzed by Gurlt, one was after simple and nine- 
teen after compound fracture, and in seven others there was simple 
fracture associated with lacerated w T ounds. 

Some autopsies have indicated as a probable cause injury to, or pres- 
sure upon, a large nerve by one of the fragments ; in other cases the 
cause appears to be the same as in wounds that are not associated w r ith 
fracture. Poland calls attention to the fact that in a number of cases 
the exposure of the patient to a sudden change of temperature seemed 
to have been the immediate exciting cause. 

Treatment holds out but a slight prospect of success. If it is known 
or suspected that a fragment is pressing on a nerve the pressure must be 
relieved. Other measures are those recommended when the affection 
complicates other wounds, and for them the reader is referred to works 
on General Surgery. Occasional successes have been obtained by the 
administration of chloral in large doses, Calabar bean, the inhalation of 
chloroform, and the division or stretching of the nerve supplying the 
region of the wound. Gurlt recommends prolonged diaphoresis, main- 
tained by hot air or vapor, in cases where chilling appears to have been 
the cause. 

Delirium Tremens and Nervous Delirium.— Nervous delirium, or trau- 
matic delirium, as it was at first called by Dupuytren, who was the first 
to describe it, resembles delirium tremens so closely that the diagnosis 
between them is not always easy to make. It presents all the symptoms 
of delirium tremens except the tremor of the limbs. There is the same 
sleeplessness, fixed delusion, loss of appetite, and insensibility to pain. 
Both occur after slight as well as after severe injuries, and as delirium 
tremens attacks habitual drinkers who are not drunkards as well as those 
who drink to excess, the differential diagnosis cannot always be guided 
by the scanty information obtainable concerning the patient's habits. 
Fortunately this is not of much practical importance, for the treatment 
is the same. 

Usually one or two sleepless nights give warning of an approaching 
attack, and if this warning is heeded, if sleep is secured by morphine or 
chloral, the bowels moved by a brisk purge, and the strength supported 
by a nutritious and easily digestible diet, the attack may be averted or 
its severity diminished. When the disease has fairly set in it must be 
treated according to the method that commends itself to the choice of 
the surgeon. These methods are numerous and differ widely ; the reader 
is referred to formal articles upon the subject. It may be said, how- 
ever, that the indications are to procure sleep, to support the strength, 



10 



Guy's Hospital Reports, 1857, p. 1. 



146 REMOTE CONSEQUENCES OF FRACTURE. 

and especially to avoid excitement and muscular action. The patient 
should be controlled not by mechanical means, such as a strait jacket 
or tying him in bed, but by the will and tact of an attendant. Holmes 
and Bryant both recommend morphine to be given subcutaneously in 
half-grain doses, a diet of beef-tea, milk, and eggs, and the avoidance of 
stimulants. 

The remote consequences or complications remaining to be considered 
are exuberant and painful callus, paralysis by injury to or inclusion of 
a nerve and secondary fracture. Failure of union and vicious union 
will be considered in separate chapters. 

Exuberant and Painful Callus. — Excessive size of the callus, common 
in the earlier stages of repair and sometimes persistent, does not require 
surgical attention unless it interferes with the functions or nutrition of 
the limb, or is due to the presence of a sequestrum or splinter or to dis 
ease of the callus itself. A different opinion was held T^y the earlier 
surgeons who sought to remedy it by diet, astringent applications to the 
surface, and compression, and, these failing, by excision of a portion. 
According to Malgaigne, it is found most frequently after fracture of the 
femur below the trochanters, and is then probably due to unreduced 
displacement of the fragments. A sudden increase in size, accompanied 
by angular or longitudinal displacement, has been observed not infre- 
quently after premature use of the limb. One of the best known cases 
is that of Weinhold of Halle, quoted by Malgaigne and most subsequent 
writers. 

The patient, a lad of 18 years, began to walk four weeks after he had 
fractured his thigh in the middle third. Six w T eeks later the limb pre- 
sented a shortening of two inches, and the callus had become enormous, 
measuring eighteen and a half inches in circumference; the surrounding 
tissue was engorged, and there were fistulous abscesses at various points. 
Extension with pulleys failing to reduce the displacement, Weinhold 
drilled into the callus an inch on the outer side of the femoral artery 
with the intention of passing a seton so as to soften it. He encountered 
in its centre a cavity four inches in diameter, passed the drill through 
and out upon the other side, and followed it with the seton. Free sup- 
puration ensued and led by the fifth week to the resolution of the en- 
gorgement of the soft parts and the closing of the fistulae ; the callus 
softened until it yielded under the pressure of the finger, and then Wein- 
hold renewed the extension with such success that by the tenth week 
there remained a shortening of only two lines. The seton was retained 
a fortnight longer, and a few weeks later the patient was able to walk 
without crutches, the thigh had regained its natural size, and the wounds 
had closed. 

In other cases, especially after gunshot fracture, the excessive forma- 
tion of callus is due to the presence of a splinter or sequestrum. These 
cases are usually marked by persistent suppuration, but it sometimes 
happens that the fistula closes and the patient remains apparently well for 
months, and even years, until, without known cause, or under the influence 
of fatigue, traumatism, or chilling, the part becomes painful and swollen, 
and an abscess forms. A number of such cases are contained in a thesis 



REMOTE CONSEQUENCES OF FRACTURE. 147 

by Tisserand, 1 of which I reproduce the following, one of splinter, the 
other of necrosis. 

Richet was called, in 1863, to see a gentleman who, seven years before, 
had broken his leg. The fracture had united after some delay, and the 
patient had resumed his usual occupations. Without known cause other 
than fatigue, the limb had suddenly become extremely painful and much 
swollen at the seat'of the old fracture. Richet thought he found deep fluc- 
tuation, and made a free incision down to the bone, but without encoun- 
tering pus ; he then forced a director into the bone, which proved to be 
a mere shell, and a gush of thick pus followed. He found within the 
cavity and removed a smooth splinter as large as the little finger. The 
wound healed promptly, and the patient had remained well up to the 
time of the last report, sixteen years afterwards. 

In 1868 the same surgeon treated a compound fracture of the leg ; at 
the end of four months consolidation appeared to be perfect. Eighteen 
months afterwards an abscess formed at the seat of fracture, bare bone 
was felt, and Richet cut down upon and removed the necrosed but still 
adherent end of one of the fragments. The patient made a complete re- 
covery. 

In a few cases an abscess has formed within the bone at the seat of 
fracture and presented the symptoms and appearances characteristic of 
the central, abscesses which are found in or near the expanded ends of 
the long bones, especially the tibia, during or just after adolescence, 
and without containing any sequestrum. One such case was reported 
by Despr&s ; 2 a man of 26, with an abscess within the tibia at the junction 
of the upper and middle thirds nine years after a fracture of the same 
bone just above the ankle. Pain had been felt about once every six 
months since fracture, and had been persistent for the five months pre- 
ceding his admission to the hospital. The case is not so demonstrative 
as I should like, for the abscess was too far removed from the seat of 
the fracture, and the patient's age was such that its formation may have 
been only a coincidence. More positive cases are contained in a thesis 
on abscesses in bone, published in Paris, if my memory serves me, by 
Ed. Cruveilhier, about 1863, but unfortunately I am unable to verify 
my recollection. The diagnosis in this class of cases is made by atten- 
tion to the recurrence of pain and swelling at the same point; the treat- 
ment is to evacuate the abscess by applying a trephine at the point where 
the maximum of pain on pressure is found. 

In addition to the cases in which the pain is certainly due to an in- 
flammatory process there are others in which pain, sometimes so severe 
as to lead to amputation, accompanies and follows regular repair without 
recognizable cause, and certainly not due to inflammation of the callus 
or bone. In some cases it has been caused by injury to, or pressure upon, 
a nerve by the edge of a fragment or the callus, and in still others it has 
been attributed to the strangulation of a nerve, within the callus. This 
complication has been made the subject of an excellent thesis by Pastu- 
raud, 3 and has been studied especially by Gosselin in his Clinique Chi- 

1 Des Abces intra-osseux consecutifs aux Fractures. These de Paris, 1879, No. 524. 

2 Bulletins de la Societe de Chirurgie, 1877, p. 584. 

3 Etude sur les Cals douloureux. These de Paris, 1875, No. 70. 



148 REMOTE CONSEQUENCES OF FRACTURE. 

rurgicale de la Charite, and the article Osteite of the Nouveau Diction- 
naire de Medecineet Chirurgie Pratiques. The latter author attributes 
the pain in the earlier periods to a non-suppurative osteitis within the 
callus, and in the later stages to an osteo-neuralgia, of which, however, 
he says he can give no explanation. Pasturaud explains it by the sup- 
position of injury to nerve filaments or nerve trunks at the time of the 
accident, an injury which results in a progressive neuritis similar to that 
observed occasionally after injuries of the soft parts alone. He supports 
his argument by a few clinical facts and by copious quotations from Dr. 
Weir Mitchell's valuable work on Injuries of the Nerves. 

The pain is usually severe, almost continuous, and increased at night. 
In a case of fracture of the leg reported by Nicod, in 1818, the suffer- 
ing increased so steadily as consolidation advanced that the patient died 
exhausted by it. In other cases it is intermittent, recurring after slight 
shocks, or movements, or even spontaneously, or after a change in the 
weather. Motor or sensory changes, paresis, hyperesthesia, or anaes- 
thesia in the limb below the fracture indicate division of and injury to a 
large nerve, as in the cases quoted below in this and the two following 
sections. Local alterations of nutrition are produced by the same cause, 
and may appear as ulcerations of the skin, atrophy of the limb, or, more 
commonly, as delay in consolidation. 

In the cases of pure neuralgia, that is, of pain without motor or sen- 
sory changes, the treatment is that of other neuralgias, and in some of 
the reported cases a complete cure has been effected by repeated blister- 
ing. In one case (Dr. Hayes Agnew, quoted by Dr. Weir Mitchell, loc. 
cit., p. 295) it was considered necessary to excise two and a half inches 
of the ulnar nerve just above the elbow ; the recovery of motion was 
almost perfect, and of sensation very great. In another, of intense 
neuralgia following a blow upon the region of the epitrochlea, Denucd 1 
cut clown upon the ulnar nerve, found it pressed upon by the displaced 
epitrochlea, excised tbp projecting part of the bone, and cured the 
patient. 

In the cases in which the associated symptoms point to inclusion of a 
large nerve in the callus, or its irritation by the bone or callus, an ope- 
ration may be undertaken for the removal of the cause. Such opera- 
tions have been successful in some cases and have failed in others. 
Thus, Prof. Trelat 2 was called to treat a child eight years old, who had 
received a fracture of the humerus in the lower third, which had united 
with much overriding of the fragments and an exuberant callus. There 
was paralysis of the extensor muscles of the forearm, a point of extreme 
tenderness on pressure corresponding to the outer and lower edge of the 
upper fragment, and hyperaesthesia of the outer surface of the forearm. 
After a long and careful search Trelat found the cutaneous branch of the 
musculo-spiral nerve imbedded in dense cellular tissue and resting upon 
the edge of the upper fragment. It had at this point the appearance of 
a ganglion, or rather of a plexus of nerves, tightly^bound together by 
fibrous tissue ; he dissected it free and excised the projecting part of the 
bone. The operation relieved the pain, but the paralysis persisted ; 

1 Diet, de Medecine et Chirurgie Pratiques, art. Conde, p. 721. 

2 Pasturaud, loc. cit., p. 49. 



REMOTE CONSEQUENCES OF FRACTURE. 149 

electricity was used until the date of the report a year later, and at that 
time the patient had not entirely regained the use of the wrist. 

In a case 1 of fracture of the forearm, in which the median nerve was 
pressed upon by the lower fragment, Prof. Hamilton excised the promi- 
nent portion of the bone, but without success. A year after the opera- 
tion the muscles of the hand and forearm were completely paralyzed, 
and from time to time very painful. 

An exuberant callus, especially if associated w T ith displacement of the 
fragments, may give trouble by pressure upon nerves and bloodvessels, 
which will require an operation for its relief. Delens 2 reports a case in 
which an exuberant callus after fracture of the clavicle caused complete 
disability of the arm by pressure upon the brachial plexus and subcla- 
vian artery. It was entirely relieved by resection. He refers to a 
case in which Vogt resected the upper end of the humerus, after frac- 
ture at the surgical neck with pseudarthrosis and exuberant callus, to 
relieve loss of power and sensation due to pressure upon the nerves. 

Paralysis due to Injury of a Nerve. — Division, laceration, or contu- 
sion of a large nerve by the broken bone, at the moment of the fracture, 
is not a common complication, but still it has been observed in connec- 
tion with fractures of all the principal bones of the limbs, the clavicle, 
and the pelvis. It is most common in the arm after fracture of the 
humerus in its middle third, or of the internal condyle, the musculo- 
spiral being involved in the former case, the ulnar in the latter. A 
number of interesting cases are given briefly by Dr. Weir Mitchell, 3 
together with references to the principal papers on the subject, the most 
complete of which are those by Ferreol-Reuiilet 4 and Callender. 5 

In a case reported by Berger, 6 occurring in the service of Prof. Gos- 
selin, the nature of the lesion was verified by autopsy. The fracture 
was at the surgical neck of the right humerus, and the symptoms were 
paralysis of the muscles supplied by the musculo-spiral nerve, anaesthe- 
sia of the back of the arm, back, and outer side of the forearm, of the 
outer two-thirds of the hand, and of the first three fingers. The patient 
died of intercurrent scarlet fever, and the autopsy showed the lower 
fragment displaced upwards and inwards, and the musculo-spiral nerve 
stretched across its edge. The nerve was reduced two-thirds in size for 
the distance of an inch, and showed a great excess of fibrous tissue with 
destruction of the nerve-tubes. 

The only case of this class, exclusive of gunshot fractures, which 
came under Dr. Mitchell's observation, was one in which the sciatic 
nerve was bruised at its point of emergence from the sciatic notch by a 
fracture of the pelvis, occasioned by a fall from i height of forty feet. 
Intense neuralgia followed and was relieved by blistering. The patient 
made a complete recovery. 

The symptoms, course, and result vary with the function of the nerve 

1 Quoted by Pasturaud, p. 47. 

2 Archives generales de Medecine, Aug. 1881, p. 170. 

3 Injuries of Nerves, p. 104. 

4 Etude sur les Paralysies du membre superieur liees anx Fractures de l'Humerus, 
Paris, 1869. 

5 St. Bartholomew's Hospital Reports, vol. vi. 1870. 

6 Bulletins de la Societe Anatomique, Juillet, 1871. 



150 REMOTE COX SEQUENCES OF FRACTURE. 

and the degree of the injury. Except after complete division, or when 
the pressure upon the nerve is permanent, recovery under appropriate 
treatment (for which the reader must be referred to special works) 
appears to be the rule. 

Paralysis by -Inclusion of a Nerve in the Callus. — A few cases have 
been reported in which paralysis of one or more groups of muscles has 
been'causecl by the pressure of the callus upon a main nerve-trunk in- 
cluded within it. This accident happens only when the nerve lies close 
to the bone at or near the point of fracture, as in the case of the mus- 
culo-spiral nerve in fractures of the shaft of the humerus. The symp- 
toms are loss of power and of sensibility, if the nerve is a mixed one, 
noticed usually on the removal of the dressings towards the end of the 
period of repair. Electrical stimulation of the nerve above the callus 
produces no effect upon the muscles, and the latter lose also their power 
of reaction to electrical currents applied directly to them. The lesion 
lies in the compression of the nerve by a fragment or by the continuous 
deposit of bone around it. It lies in a groove or tube, the calibre of 
which steadily diminishes by progressive deposit of bone upon its sur- 
face, just as the vascular canals of new or inflamed bone diminish in 
productive or condensing osteitis ; but as all attempts made to produce 
this condition experimentally have failed, we must believe that the ten- 
dency to this filling up of the channel or tube in which the nerve lies is 
slight. Probably an associated neuritis is required to effect the result, 
one due, not to the strangulation of the nerve, but to antecedent bruis- 
ing. The treatment consists in the liberation of the nerve and its sub- 
sequent stimulation by the interrupted or, better, the constant current. 
The following case illustrates the prominent features, and is the first in 
which an operation was done to relieve the disability. 

L, 1 22 years old, received a compound fracture of the right humerus 
at the junction of the lower two-fifths and the upper three-fifths, with 
projection of the lower fragment. The limb was placed in a starch 
apparatus and kept there for forty days. During the first few days the 
patient complained of sharp lancinating pain at the seat of the fracture. 
On removal of the apparatus complete paralysis of the extensor muscles 
of the hand was discovered. 

Four months after the accident he consulted Oilier, who found the 
bone firmly united with a slight increase in its size at the seat of frac- 
ture, and with inequalities behind that were easily recognizable by the 
finger. The forearm was atrophied, and there was complete paralysis of 
the extensors and of all the muscles of the forearm supplied by the 
musculo-spinal nerve. No electrical reaction in these muscles, notable 
diminution of sensibility in the thumb and forefinger. Pressure over 
the course of the nerve just below the callus caused vague sensations in 
the posterior portion of the forearm. 

After using electricity for two months without any gain M. Oilier 
made an incision three inches long in the course of the nerve at the level 
of the callus, and on dissection found a branch of the nerve which he 
traced back into the callus. He then cutoff a portion of the callus care- 

' Oilier. Traite de la Regeneration des On, vol. ii. p. 414. 



REMOTE CONSEQUENCES OF FRACTURE. 



151 



fully with a chisel and exposed a closed canal in it in which was found 
the nerve ; the canal was then laid open upwards and downwards for a 
distance of two inches, and the nerve liberated. It was compressed at 
one point to a diameter of J-th inch by a spicula of bone, apparently a 
portion of the lower fragment, and enlarged above it to a diameter of 
nearly half an inch ; below the compressed part the size was normal. 
The spicula was cut away, the nerve loosened from the underlying bone, 
the adjoining periosteum removed, and the wound closed. The paralysis 
of sensation and motion gradually disappeared, and the patient was 
completely cured. 

In another case reported by Delens, 1 the same paralysis was observed 
after fracture of the humerus in the lower third, a few days after the 
removal of a plaster splint which had been applied immediately after the 
accident and kept on for forty days. At the ope- 
ration the nerve was found lodged in a bony 
groove of new formation, flattened, and incrusted 
with spicule, also of new formation. It was 
liberated, and the wound closed. Within a 
week the power of voluntary motion had been 
partly recovered, but afterwards, under the in- 
fluence of a diffuse phlegmon of the other arm 
originating in a vaccination pustule, it was again 
lost, and was only regained imperfectly. 

Secondary Fracture. — It occasonally hap- 
pens that after a fracture has united and the 
patient has begun to use the limb again, or has 
even used it for some time, the callus or the bone 
breaks again at the same point. It has been 
shown that the callus is composed of a more or 
less bulky mass of spongy bone, which requires 
considerable time to acquire its full strength 
and to become firmly united with the principal 
fragments. During its evolution, therefore, it 
is liable to be broken or separated from the 
fragments by the action of any such force as 
may cause a fracture in a normal bone, and the 
shorter the period that has elapsed since the original accident the greater 
is this liability. Furthermore, if the fragments are so displaced that 
they give each other but little support and the strength of the union 
depends solely upon the solidity of the callus, this liability to fracture 
is still further increased. Consequently, we find secondary fracture 
occurs in the great majority of cases soon after the splints have been re- 
moved and the patient begins to use his limb, and especially after frac- 
tures of the shaft of long bones that have united with much displacement. 
It is rare, if not unknown, after fracture of the short spongy bones or of 
the expanded extremities of the long ones. It may be complete or in- 
complete, resembling in the latter case the infraction or bending described 
in Chapter II. It is produced by the same causes as an ordinary frac- 




Ollier's case of inclusion of 
the musuclo-spii 
the callus. 



nerve 



1 Bulletins de la Societe de Chirurgie, 1880, p. 26: 



152 REMOTE CONSEQUENCES OF FRACTURE. 

ture, by muscular action, or even, in the lower extremity, the weight of 
tlfe body in walking. 

Experiments were made by Jacquemin 1 to determine the amount of 
force necessary to produce a secondary fracture. He took the femur of 
a man who died of pneumonia forty-five days after its fracture, cleaned 
it, and fixed it upon a table with the callus and long fragment projecting 
beyond the edge, and attached weights to the projecting end. 62 pounds 
caused the callus to bend without apparent rupture ; Q6 pounds caused 
complete separation, the callus remaining attached to the upper fragment. 
An oblique fracture of the humerus treated in the same manner after death 
on the fifty- ninth day bent and broke under a weight of less than 62 pounds. 

The periods at which secondary fracture has been observed vary from 
a few days or weeks to several years ; in the latter cases the violence 
that produces it is usually such as would be thought sufficient to cause 
fracture of the bone in its normal state. In exceptional cases repeated 
fracture occurs after slight causes, and is then to be attributed to defec- 
tive formation of the callus. In 87 cases analyzed by Gurlt, it occurred 
20 times in the femur, 11 times in the leg, 3 times in the forearm, twice 
in the arm, and once in the clavicle; in 2 (femur and leg) it occurred 
twice, and in 1 (femur) three times. In 3 cases the secondary fracture 
was incomplete (infraction), at intervals of 13 weeks, 133 days, and about 
6 months ; the patients being 19, 16, and 13 years of age respectively. 

The symptoms are the usual ones of fracture : mobility and crepita- 
tion ; or, in the case of infraction, deformity by the production of an 
angle at the point of fracture. The treatment is the same as for an 
ordinary fracture: reduction and contention for the complete ; reduction, 
rapid or gradual, and contention for the incomplete. Advantage, when- 
ever it is necessary and possible, must be taken of the accident, to over- 
come any previous displacement that may have favored the production 
of the second fracture. In fractures that recur more than once, shorten- 
ing, often to a considerable extent, is to be expected. Gosseiin 2 reports 
a case of a man of 25, who broke his femur six times in the course of 
twenty months. The fractures did not occur when he began to Walk, 
but from the eighth to the fifteenth day thereafter, and generally in con- 
sequence of a slight effort, either to save himself from falling or to run, 
and once while dancing. Each time the patient had been allowed to get 
up on the forty-fifth day. Gosseiin saw him after the last fracture, kept 
an apparatus on for two months, and the patient in bed for three months. 
There was permanent shortening of 2J inches. 

In three other cases observed by the same surgeon secondary frac- 
ture occurred in young men who, in disobedience of instructions, left 
their beds and attempted to walk at about the fiftieth day. The prac- 
tical conclusion is that after fractures of the femur patients should not 
be allowed to use the limb, even with crutches, until the seventieth or 
seventy-fifth day, notwithstanding apparent firmness of the union, and 
that splints should be kept for the same length of time upon patients 
whose obedience and reasonableness cannot be counted upon. 

1 These inaugurale, Paris. 1822, quoted by Malgaigne. 

2 Clinique Chirurgicale de l'Hopital de la Charite, vol. i. p. 389. 



TREATMENT OF FRACTURES. 153 



CHAPTER VIII. 

TREATMENT OF FRACTURES. 

The treatment of a fracture, strictly speaking, begins immediately 
after the accident that has caused it. Unfortunately for the patient, the 
first attentions are usually given, and his removal to his home or to the 
hospital carried out, by bystanders who do not fully appreciate the ex- 
tent to which the injury already received may be aggravated by their 
well-meant but sometimes ill-judged interference. Or the patient him- 
self, moved by a natural but equally harmful impulse to convince himself 
that he has not been seriously hurt, attempts to use his injured limb, and 
thus increases the displacement and the laceration. It is of great im- 
portance that this aggravation of the injury by unnecessary movements 
of the limb should be avoided ; it is most liable to occur when the frac- 
ture involves the lower limb, and under such circumstances the patient 
should not be moved except upon a stretcher, and preferably after the 
application of a temporary splint. When a bone of the arm or forearm 
is broken sufficient immobility is obtained by supporting the limb with 
the other hand or in a sling. 

Afer the clothing has been removed and the diagnosis made, the 
patient should be placed, if the fracture is of the lower extremity, upon 
a narrow bed furnished with a mattress and springs, nob soft enough 
to yield noticeably under the weight of the body. If necessary, the 
firmness of the bed may be increased by placing planks lengthwise under 
the mattress. In cases of severe compound fracture of the femur it may 
be desirable to use a "fracture bed," of which there are many varieties 
in the market, designed to allow the bedding to be changed, the natural 
wants of the patient attended to, and the wound dressed without change 
of position. A simple arrangement which will meet the indications suf- 
ficiently well can be readily made with the aid of a carpenter. A stout 
rectangular frame, three feet wide and a little longer than the patient, 
is made and fitted with metal buttons or hooks at intervals of a few 
inches along the outer surface of its two sides, to which strips of stout 
cotton cloth six or eight inches wide can be attached by eyelets or cords. 
Two ropes, each about nine feet long, fastened by their ends to the four 
corners of the frame, complete the arrangement. The frame is placed 
upon the bed, and the patient upon it ; when it is desired to raise him 
from the bed the slack of the tw r o ropes is engaged in the hook of a pul- 
ley, the mate of which is attached to the ceiling immediately above the 
centre of the bed or to a frame constructed for the purpose. If the 
bands lying under the pelvis and upper portion of the thigh have been 
previously removed, the bed-pan can be conveniently used. The strips 



151 TREATMENT OF FRACTURES. 

can be changed by attaching a fresh one to the end of the one it is to 
replace, and drawing both through. 

In the usual run of cases a bed-pan can be used without giving pain 
to the patient or disturbing the process of repair, and I have never found 
it necessary to use a device which, I fancy, is more frequently recom- 
mended than employed ; that of cutting a hole in the centre of the mat- 
tress and lining it with some water-proof material. Sheets may be 
changed by folding half of the fresh one longitudinally, turning the pa- 
tient slightly upon one side, placing the folded portion under him, turning 
him then upon the other side, and drawing the fold through ; or by attach- 
ing the end of the fresh sheet to the upper end of the soiled one and work- 
ing both down gradually to the foot of the bed, while first the shoulders 
and then the hips of the patient are slightly raised to aid the process. 

Bed-sores are best guarded against by keeping the bed-clothing 
smooth and the skin dry, bathing exposed points occasionally with alco- 
hol, camphor spirits, vinegar, or ether, mixed with twice the quantity of 
water, and by using inflated rubber rings under the pelvis. If they 
become imminent the affected surface should be painted with a thick 
coating of flexible collodion, and every effort made to protect it from 
pressure. If they occur they must be treated, according to circum- 
stances, with emollient or stimulating dressings. When not otherwise 
contra-indicated the water-bed may be used with great advantage. Bry- 
ant says he has found a mattress divided into three parts, and a water 
cushion substituted for the middle section, of great use. 

The aim of treatment is to secure prompt and firm union with the 
minimum of deformity and disability. It comprises two main indica- 
tions : 1st, to reduce the displacement, to "set*' the fracture ; 2d, to main- 
tain this reduction ; and, while both these indications can sometimes be 
met with much ease, there are other occasions on which the former is im- 
possible or the latter taxes the professional and mechanical skill of the 
surgeon to the utmost. 

By the reduction or setting of a fracture is meant the restoration of 
the fragments to their normal positions and the consequent removal of 
such displacements as may exist. As most fractures of the limbs are 
accompanied by shortening, reduction is usually effected by traction,, or, 
speaking technically, by extension and counter-extension, aided, when 
necessary, by lateral pressure to bring the fragments into line, coaptation, 
and by rotation to correct rotatory displacement. When angular dis- 
placement alone exists, as in incomplete fracture, lateral pressure upon 
the angle with the thumbs, while counter-pressure is made by the fingers 
grasping the limb above and below, is the means usually employed ; and 
in longitudinal displacement with separation, as after fracture of the pa- 
tella, the downward traction is made of course upon the upper fragment. 

Usually considerable force must be exerted to overcome the contrac- 
tion of the muscles which has followed or produced the displacement, 
but the amount of this force and its effectiveness vary within wide limits. 
The older surgeons found in the spasm of the muscles provoked by the 
traumatism, and in the acute inflammatory processes of the first stage, an 
argument for postponing all attempts to reduce the fracture until after 
the spasm and the inflammation had yielded to antiphlogistic treatment 



TREATMENT OF FRACTURES. 155 

and rest, but it is now well understood that the best means of subduing 
the one and preventing the other is be found in the early reduction of 
the displacement and the prevention of its return, and the general rule 
of treatment now is to set the limb at the earliest possible opportunity, 
usually at the first visit, whether it be immediately after the accident or 
only after the lapse of several days, using an anaesthetic, if necessary, 
to overcome the resistance of the muscles. The exceptions to the rule do 
not annul it entirely in the cases to which they apply, but only limit the 
degree to which it should be carried out. They are found in exagger- 
ated muscular spasm and in acute painful inflammation of such an extent 
as to prevent the application of a retentive apparatus sufficient to main- 
tain the reduction. The rule is positive to make as much reduction as 
can be made without using extreme force and as can be maintained with- 
out dangerous pressure upon the limb. It is a rule which is radically 
incompatible with routine practice and requires the best judgment and 
tact of the surgeon ; its guiding principles are : 1st, that reduction, to 
any extent, diminishes pro tanto the irritation and reaction due to the 
fracture ; 2d, that excessive force employed to accomplish reduction may 
cause additional lesions, the consequences of which are worse than those 
of displacement ; and 3d, that more or less complete reduction is still 
possible one, two, or three weeks after the receipt of the injury, that is, 
at a time when two important obstacles to reduction, spasm and inflam- 
mation, have ceased. 

The objection to the employment of extreme force lies in the danger 
of thereby rupturing an important vessel in case the resistance should be 
due to some mechanical cause, or of causing persistent pain, convulsions, 
or even tetanus if it is due to muscular spasm. Cases of death caused 
in both these manners are on record. Severe inflammation is a contra- 
indication to the use of force for two reasons : by involving the muscles 
it diminishes their extensibility greatly and thus opposes a mechanical 
obstacle that cannot be overcome without rupture of the stiffened fibres ; 
and the exudation that accompanies it increases the bulk of the limb to 
such an extent that its forcible elongation results necessarily in a great 
increase of the tension under the enveloping fascia. The rupture of the 
muscular fibres adds to the existing traumatism and increases the chance 
of suppuration ; and the tension may become so great as to cause gan- 
grene by interference with the circulation. These are the dangers to 
be avoided and especially to be borne in mind when the use of an anaes- 
thetic deprives the surgeon of the warning that w r ould otherwise be given 
by the pain occasioned by the traction. 

Ordinary muscular spasm can be annulled by ether or opium, but if 
the former is used care must be taken to prevent violent movements of 
the limb during the stage of excitement. In a case of fracture of the 
leg Broca overcame the spasm very cleverly by compressing the femoral 
artery for a few moments. The spasm, which had been so violent and 
painful that it was impossible to handle the limb, disappeared immedi- 
ately ; the limb was placed in an apparatus, and the spasm did not return 
until the dressing was changed. Pressure was then again made with the 
same success. This method promises sufficiently well to justify its use 
in some cases before recourse is had to anaesthetics ; it enabled me to 



156 TREATMENT OF FRACTURES. 

reduce a fracture of the leg that would not yield to traction by the hands. 
Gradual, continuous extension by India-rubber, or by a weight and pul- 
ley, may be trusted to overcome any pure muscular spasm when it can 
be employed, but it is applicable only to cases where the seat of the 
fracture is sufficiently high upon the limb to allow the proper attach- 
ment of the bands. Spillmann 1 recommends as of occasional service the 
internal administration of atropia with a view to reduce the spasm, or 
the local use of an ointment containing belladonna and mercury when 
the spasm is associated with inflammation. 

Inflammation is to be treated by reduction of the displacement, so far 
as possible, and by poultices. If it advances to suppuration the pus 
must be promptly evacuated and the fracture then treated as a com- 
pound one (q. v.). While waiting for the proper time to make complete 
reduction the limb must be immobilized by temporary dressings, with the 
fragments in the best attainable position, by the aid of fracture-boxes, 
cushions, inclined planes, or temporary splints. 

Reduction is made, as has been said, by extension, counter extension, 
and coaptation ; the first two, acting together, are intended to restore 
the limb to its original length by drawing the fragments past each other ; 
the third is exerted transversely to bring them into line. There has 
been much discussion in the past concerning the position in which the 
limb should be held while reduction is made, some preferring extension, 
others flexion. Since the introduction of anaesthetics the question has 
lost much of its interest, but the fact remains that ordinarily the muscu- 
lar resistance is less when the limb is partly flexed than when it is fully 
extended, and, therefore, that this position should be chosen whenever 
any important resistance is offered by the muscles. Practically, it is 
desirable that the limb during reduction should be in the position it is to 
occupy during treatment, in order to avoid the risk of reproducing the 
displacement during the change that would otherwise be necessary. 
Most fractures of the arm and forearm are reduced and treated with 
the elbow flexed, those of the femur with the knee extended, and those 
of the leg with the knee extended or slightly flexed. 

Extension is best made by traction with the hands applied to the lower 
end of the broken bone, or to the distal segment of the limb if the 
fragment is too small to be readily grasped or if the limb is too tender. 
Counter-extension is made at similar distances from the seat of fracture 
by the hands of another aid, or by bands made fast to a neighboring 
fixed point. The surgeon meanwhile applies his own hands to the seat 
of fracture to appreciate the movement of the fragments, and to make 
coaptation at the proper moment. These general rules are, however, 
subject to many exceptions depending on the character of the displace- 
ment and the difficulties of the reduction. The traction should be mod- 
erate and, above all, steadily continuous ; and, generally speaking, the 
fragments should be brought parallel to each other before the traction is 
begun ; the latter is then made in the direction of the long axis of the 
limb. It should be continued for a few moments, while the surgeon 
watches the change in the length of the limb and in the relation of the 

1 Dictionnaire Encyclopedique des Sciences Med., 4tli series, vol. iv. p. 70. 



TREATMENT OF FRACTURES. 157 

fragments to each other, and makes gentle pressure on the sides of the 
limb to overcome lateral displacement. If the bone is superficial and 
the swelling moderate he may be able to recognize plainly the irregu- 
larities of the surface due to the displacement, and note their disappear- 
ance when the reduction is complete ; but if the bone is covered by thick 
muscles his only guide may be the length of the limb, of which he can 
judge by his eye, or by measurement. Sometimes reduction takes place 
with distinct crepitus, but the sign is of no great value, since it is some- 
times absent in complete, and present in partial, reduction. While the 
effort is making the patient must be enjoined to maintain as complete 
muscular relaxation as possible ; he should be recumbent, and should not 
be allowed even to raise the head, and this quiescence should be main- 
tained until after the retaining dressing has been applied. 

It goes without saying that the reduction must include the other dis- 
placements, as well as the longitudinal and transverse, and in fracture of 
the lower extremity especial care must be given to the correction of 
rotatory displacement, and with that view the attention must be directed 
to the relations of the different bony prominences which may serve as 
guides, and they must be carefully compared with fixed and known 
standards, or with those furnished by the other limb. 

It sometimes happens that complete reduction is difficult or impossible 
for other reasons than those already mentioned. Thus, when a small 
spongy bone or the expanded extremity of a large one has been crushed, 
so that there is an absolute loss of substance embracing the whole or 
only a portion of the thickness, either with or without impaction of one 
fragment in the other, it may be impossible to grasp the pieces so as to 
make the traction necessary to separate them, or to keep them, if sepa- 
rated, at a proper distance on account of the destruction of the inter- 
mediate portion. An instance of this firm impaction is reported by 
Stanley. 1 A man received a fracture at the lower end of the leg by the 
passage of a cart-wheel over it. All attempts to reduce the displace- 
ment were ineffectual, and after his death on the tenth day, and the re- 
moval of the soft parts by dissection, it was found difficult to separate 
the fragments, so firmly were they impacted. A similar case, of impac- 
tion at the lower end of the radius that could be overcome only by con- 
siderable force after dissection, has been reported by Dr. L. S. Pilcher. 2 

The same difficulty may be experienced after fracture of the diaphysis 
with much comminution, either because the small fragments become 
lodged between the large ones in such a way as to effectually oppose 
their adjustment, or because their minute shattering and compression 
produce the effect of an absolute loss of substance in their failure to 
afford support. Even when the comminution involves only a portion of 
the thickness of the shaft the same difficulty exists, because the remain- 
ing portions touch each other by too limited an area. Or the projec- 
tions of a toothed fracture on one fragment may be engaged in other 
than their corresponding depressions on the other one, and the best 
efforts of the surgeon may be ineffectual to disengage them. Or, in an 

1 London Med. Gazette, 1844-45, vol. i. p. 274. 

2 Annals of Anatomy and Surgery, March, 1881, p. 116. 



158 TREATMENT OF FRACTURES. 

oblique fracture the anterior point, for example, may have been carried 
behind the posterior one, and the condition may not be recognized. 
Lisfranc is reported to have reduced the displacement in such a case by 
carrying the fragment laterally around the other, a manoeuvre which 
could not be expected to always succeed even if the diagnosis were 
correctly made. 

When the fracture involves the ankle-joint the external malleolus and 
foot may be dislocated outwards so far as to allow the astragalus to slip 
up between the tibia and fibula, as in figure 49, and to be wedged there 
too tightly to permit of reductien by the means usually at command. 
An example of this displacement, irreducible during life and verified by 
autopsy, is reported in the Bulletin cle la Soeiete de Chirurgie, 1880, p. 
436. The patient was a woman, 58 years old, and had produced the 
fracture by an effort to draw off her boot with her hands, the foot twist- 
ing outward. 

There are other cases, too, in which reduction cannot be made because 
it is impossible to act upon the displaced fragment on account of its 
small size, or of the depth at which it is placed. Examples of the first 
are presented in fracture of the patella, of the coronoid process of the 
ulna, and of other small apophyses to which powerful muscles are at- 
tached, and also of fragments, articular or otherwise, which have been 
displaced to a considerable distance. Examples of the second are seen 
after extreme displacement or rotation of the articular end of a long 
bone after its separation from the shaft by fracture ; and a somewhat 
similar condition is found in fractures combined with dislocation. The 
same inability to properly handle the fragments is found also after frac- 
ture of the trunk or head, and frequently involves permanent deformity. 

Finally, a serious obstacle to reduction may exist in the perforation 
of the overlying muscles and fascia by the sharp end of a fragment, or 
in the interposition of a bundle of muscle between the fragments. It is 
all the more serious because it is often difficult of recognition, and, when 
uncorrected, results in failure or retardation of union, or in union by an 
insufficient callus. An interposed bundle of muscle, if small, may be- 
come imbedded in the callus and disappear after a time by absorption, 
and therefore expectative treatment may properly be followed ; but 
when the end of a fragment has penetrated a muscle to a considerable 
depth, the displacement must be overcome. The accident is most com- 
mon in oblique fractures of the lower portion of the femur and of the 
upper portion of the humerus, the penetration being made by the lower 
end of the upper fragment in the former case, and by the upper end of 
the lower fragment in the latter. Recourse is first had to full extension 
in the hope of thus withdrawing the bone from the tissues in which it 
has buried itself. That failing, an operation becomes necessary sooner 
or later. It has been recommended and practised to insert a tenotome, 
divide the muscle below the end of the fragment by short cuts, and then 
to press the divided surfaces away, and thus open a route for the return 
of the bone to its place. In a case in which Laugier is said to have 
thus divided the perforated fascia of the thigh an abscess formed and 
led to the death of the patient by pyaemia. Nevertheless, I think few 
surgeons would hesitate now to cut freely down upon the bone, under 



TREATMENT OF FRACTURES. 159 

antiseptic precautions, for the purpose of correcting an otherwise irre- 
mediable displacement which, if left to itself, would cause complete 
disability. When the perforation involves the skin also, and the frac- 
ture is already compound, there can be no hesitation. Nothing is lost 
by enlarging the wound and thus gaining an opportunity to make the 
reduction intelligently, and, therefore, with the least laceration and 
violence. (See Treatment of Compound Fractures.) 

Retention. — It occasionally happens that the tendency to displace- 
ment is so slight that, after the reduction of the fracture, the limb may 
be left without other dressing than such as may be designed to protect 
it from accidental violence. But in the vast majority of cases a dress- 
ing is required to resist the tendency of the muscles or of gravitation to 
produce displacement, and to secure immobility ; and the same indica- 
tions exist also in those cases in which only incomplete reduction is 
possible. The principles that govern the construction of the retaining 
apparatus are closely allied to, and sometimes identical with, those of 
reduction. In some cases the best retaining dressing is a moderate, 
continuous, active extension, supplemented by lateral support at the 
seat of fracture ; in others it is rather a passive extension, that is, a 
fixed inelastic apparatus, which, while not making extension, resists 
retraction ; in others, again, it is mainly lateral support to prevent 
angular or transverse displacement and to secure immobility. The 
details require that points of special pressure shall be guarded by 
cotton-batting, wool, or compresses, and that the limb shall not be 
wrapped circularly in such a manner as to expose it to gangrene. It 
may be necessary to bandage the distal portion of the limb to prevent 
oedema ; but except under rare conditions when its use is clearly indi- 
cated, such as hemorrhage, a roller-bandage should not be applied to the 
broken or upper portion of the limb under the splints. If pressure is 
desired to reduce a swelling or moderate inflammation, it should be 
elastic or at least capable of yielding, if the pressure is increased from 
within, and, in addition, should be most carefully watched. The best 
material is cotton-batting applied smoothly and evenly under a bandage. 
Pain cannot be depended upon to give warning of too great pressure or 
impending gangrene ; the fingers or toes should be left exposed to view, 
and the surgeon should make it an invariable rule to examine their sen- 
sitiveness and the circulation in them by pressure upon the nails and by 
feeling for pulsation in any accessible distal arterial branch immediately 
after a dressing has been applied, and at every visit for the first few days 
thereafter. If it is feared that the principal vessels or nerves have been 
injured by the accident, it is often best not to attempt complete reduc- 
tion and retention at first, but merely to support the limb in a good 
position until the full extent of the injury shall have become apparent. 
In many litigations the question upon which the verdict depended has 
been whether the gangrene was due to the original injury or to an ill- 
applied dressing, and the surgeon should protect himself as far as possi- 
ble against the doubt. 

The choice of a dressing in simple fractures uncomplicated by severe 
injury to the soft parts depends in a measure upon the character of the 
displacement the tendency to which it is designed to correct ; and 



160 TREATMENT OF FRACTURES. 

although many of the dressings and splints meet more than a single 
indication of this kind, and although, furthermore, an indication can 
usually be met in more than one way, it seems best to describe the 
dressings as nearly as possible in groups based upon this pathological 
difference. I shall describe only those that are now in general or occa- 
sional use, and shall leave some details to be noticed in connection with 
special fractures. 

The first group comprises those which are intended simply to im- 
mobilize the limb or to effect contention by pressure, usually lateral. 
They are theoretically applicable especially to meet the tendency to 
transverse or angular displacement. The second comprises those which 
make active extension, or which maintain an extension previously gained. 
Their primary object is to overcome longitudinal displacements. These 
two forms merge into each other by intermediate forms possessing the 
qualities of both in varying proportions. Dressings are also classified 
sometimes according to the facility with which they may be readjusted 
or removed, as movable, immovable, and amovo-inamovible or removable- 
fixed. The first class includes all composed of bandages, cushions, and 
splints ; the second includes those which harden after they have been 
placed upon the limb, such as the starch, dextrine, and gypsum dressings ; 
and the third those composed of hardening materials arranged in sec- 
tions that permit removal without destruction of the dressing. 

The Scultetus Bandage (figs. 78 and 79). — This is a combination of 
short bands and wooden splints which was in very general use before 
the introduction of fixed dressings, and is still employed in some excep- 
tional circumstances. It is composed of a large number of small bands, 
a broad cloth, two long wooden splints, and two long narrow cushions 
made of muslin stuffed with horse-hair, cotton, wool, or straw. It is 
prepared for use as follows : A piece of stout cotton cloth, of a length 
and breadth somewhat greater than the length and circumference of the 
limb that is to be immobilized, is spread out upon a table ; then, be- 
ginning at its upper end, bands of the same material three or four inches 
wide, and one-half longer than the circumference of the limb are placed 
transversely upon it, each successive band overlapping the lower border 
of its predecessor about one inch. The cushions and the splints, each 
having about the length of the first piece of cloth, and a breadth of three 
or four inches, are placed along its sides, the edges of the cloth turned 
over them, and each rolled in until they meet in the centre. The band- 
age is now ready for transportation or use. If required, for example, 
for a fracture of the leg, the limb is raised from the bed, the bandage 
placed lengthwise under it so that its lower border projects a little be- 
yond the loot, and is unrolled, and the limb lowered upon it. One end 
of the lowest transverse band is raised, carried over the front of the leg 
and around the other side as far as it will go, and its other end brought 
back over it in like manner. This is repeated with each successive 
band, and after all have been applied the splints are rolled up in the 
broad piece of cloth, one on each side, until they rest against the side 
of the leg, separated from it, however, by the cushions, and the whole 
is secured by a few strips of bandage. Sometimes a short anterior pad 
and splint are added. 



TREATMENT OF FRACTURES. 



161 



The advantages of the dressing are the facility with which the limb 
can be uncovered without disturbing it, and the equable and gentle 
pressure which it makes. Its disadvantages are its complexity, and its 



Fis:. 78. 



Fig. 79. 





The Scultetus bandage ready for use. Th< 
not shown. 



splints and cushions are 



Scultetus bandage applied 
to the leg. 



Fiff. 80. 



comparative inefficiency to prevent displacement. Its use is now gene- 
rally restricted to cases which do not admit of a more efficient apparatus 
on account of inflammatory swelling, threatening gangrene, or extensive 
contusion, and to some compound fractures in 
which the antiseptic gauze is applied in this 
manner. It is seldom applicable except to frac- 
tures of the leg. It must be borne in mind that 
it is not incapable of causing strangulation of 
the limb, and therefore calls for the same 
watchfulness as other enveloping dressings. 

Bivalve cushion (figs. 80 and 81). This is 
a simple dressing that can be readily made of 
materials that are always at hand, and is there- 
fore of great use to the country practitioner or 
in an emergency, and meets very well the in- 
dications of treatment during the first few 
days. It was invented by a French surgeon, 
named Laurencet. A rectangular sac of stout 
cotton cloth, of a length and breadth suited to 
the size of the limb, is divided into two parts by a seam which, be- 
ginning at the centre of its lower border, passes directly upwards for 




Bivalve cushion. 



162 



TREATMENT OF FRACTURES 



one-third its length, and then bifurcates so as to leave a central V- 
shaped portion, the base of which is at the upper border of the sac, and 
is about three inches wide. The two lateral pouches thus formed are 
stuffed, and the. openings closed. The limb is then placed along the 
centre, the two sides raised and supported by lateral splints, and the 
whole secured by the straps. If used in fracture of the leg, it is well 
to have the lower end of the sac project sufficiently beyond the sole of 
the foot to allow it to be turned in and fixed so as to support it. 
Yalette speaks very highly of the firmness and. security of this dressing; 

Fig. 81. 




Bivalve cushion applied to the leg. 

as the cushions are united to each other, they cannot become displaced 
with the facility which characterizes separate lateral pads and splints. 

Wooden splints are made preferably of soft white wood which lends 
itself easily to the cutting and shaping necessary to make them fit. 
Their main use is as lateral or coaptation splints, padded or applied over 
cushions so as to fit accurately without undue pressure upon prominent 
points. They are also serviceable in some compound fractures to give 
the necessary solidity while allowing easy exposure of the wound. A 
splint is made by cutting the wood to fit approximately the limb in length 
and breadth ; cotton cloth is then stitched loosely about it with an open- 
ing left at one end through which the padding, cotton, wool, curled hair, 
or some similar material, is introduced and distributed according to need, 
or cotton batting is laid upon the splint and secured by wrapping it with 
a bandage or thread. The carved splints prepared and offered for sale 
by dealers in instruments are vigorously condemned by most authors, 
and rightly so, in my judgment, if they are assumed to be fit for use 

in the shape in which they are 
offered. They need the same pad- 
ding and adjustment that an im- 
provised splint does, and their prin- 
cipal advantage is that, beingalready 
partly modelled, they need some- 
what less. A convenient form for 
some cases is Gooch's flexible 
wooden splint, which is made of thin narrow strips pasted close together 
upon stout cloth or leather (fig. 82). 



82. 



Gooch's flexible wooden splint. 




TREATMENT OF FRACTURES 



163 



Fracture boxes are a variety of the wooden splint applicable to frac- 
tures of the leg. Their use in simple fractures is mainly a temporary 
one, because there are other and better permanent dressings, but they 
are frequently used in compound fractures throughout the entire period 



Fio-. S3. 




Petit's fracture box. 

Fisr. 84. 




Scheuer's box splint. 



of treatment. Figures 83, 84, and 85, show the principal varieties and 
render a detailed description unnecessary. They must be fitted with 



Fisr. 85. 




Baudens's fracture box. 



cushions and pads for the reception of the limb, and with bands or straps 
to immobilize it and prevent displacements. It is well to support the 



164 



TREATMENT OF FRACTURES. 



Fig. 86. 




foot by a broad strip of adhesive plaster, which, beginning well up on 
the calf, is brought under the heel and along the sole of the foot, and 
tacked to the top of the foot-piece of the splint. By this means painful 
pressure upon the heel can be avoided. 

Gutters made of wire in a great variety of patterns are also in fre- 
quent use, and occupy a position intermediate between fracture boxes and 
moulded splints. A galvanized wire frame, or wire gauze strengthened 
at the edges, shaped to roughly fit the limb, is padded with cotton or 
cushions and bound on firmly by means of circular straps or bands. 

Those intended for the upper 
extremity are usually bent at 
a right angle at the elbow, 
those for the lower extremity 
straight or slightly bent at the 
knee, cut out at the heel, and 
fitted with a short cross-piece 
at that end to prevent rotation. 
Sometimes they are jointed at 
the knee or elbow, and in some 
cases the sides are hinged. 
Wire gauze is more commonly 
used now than wire frames, and 
the meshes of the latter should 
be smaller than those shown in 
figure 86. This mode of dress- 
ing has found its most complete 
expression in Bonnet's large gutters for the treatment of fractures of 
the thigh, which support the entire body, or in Palasciano's modification 



Wire gutter for th 




Bonnet's gutter for the leg. 



which is jointed at the hip, and allows the limb to be placed in the ex- 
tended or flexed position. The material yields sufficiently to lateral 
pressure to allow a certain amount of modeling to the irregularities of 
the limb, and as they are open in front an anterior pad and splint can be 
used if needed. 

Posterior and suspended splints are classified by foreign writers as 
liyponarthecic (from vrto under, and vapfljji, a splint^), a term which at 
first, as its etymology indicates, was applied only to posterior splints, 
but is now used to designate all suspended dressings. The aims of these 



TREATMENT OF FRACTURES. 



165 



dressings are to maintain the limb, especially the lower one, in a flexed 
position, to permit movements of the body without disturbance of the 
fractured bone, and to enable the surgeon to examine all portions of the 
.limb and to dress its wounds 
with the least disturbance and 
pain. The varieties are numer- 
ous, but follow two main types : 
a firm posterior splint or support 
upon which the limb rests ; and 
an anterior frame or splint from 
which the limb is suspended by 
bands or sheets passing under 
it. In either case the splint is 
suspended from a cradle or a 
hook at a certain height above it. 
The simplest, and, perhaps, the 
least efficient, is Mayor's (fig. 
88), composed of a plank or 
wire frame suspended by cords 
attached to its corners. The 
limb rests upon it on a cushion 
and is immobilized by bandages 
fastened about the foot and dif- 
ferent portions of the limb. Mclntyre's splint provides also for con- 
tinuous extension, and, combined with Salter's suspension cradle (fig. 
89), is a favorite dressing. Nathan R. Smith's anterior splint (fig. 91) 




Mayor's suspension dressing 



Fiff. 89. 




Mclntyre's splint and Salter's swing. 

was much used during the War of the Rebellion in the treatment of 
gunshot fractures of the thigh. It is composed of two parallel pieces 
of stout iron wire joined at the ends and by two or three intermediate 
rods, slightly flexed at the knee, and bent upwards at each end to fit 
the foot and the pelvis when the thigh is flexed. It is placed along the 
anterior surface of the limb and is bound to it by a roller bandage or 



166 



TREATMENT OF FRACTURES. 



by straps. A pulley and rope furnished with two hooks provide for 
suspension. Hodgen's splint (fig. 92) is similar in construction, but 



Fig. 90. 




Suspended fracture box for compound fractures. 



gives a firmer support and provides permanent extension in fractures of 
the thigh, if, as he suggests, the supporting hook is placed beyond the 



Fig. 91. 




a 



a 



i j? i 



Nathan E. Smith's anterior splint. 

foot, or if it is fitted with an extension apparatus. Mr. Bryant 1 says, that 
in seventeen cases of fracture of the femur treated at Guy's Hospital 
by this splint the average shortening was less than half an.inch, and that 
in six cases there was none. He found, however, after a lengthened 
trial, that a much larger amount of callus was formed than when he used 
the double lateral extension splint, and inferred that there was more 
mobility during treatment with the former than with the latter, and 
therefore discarded the Hodgen. 

Hodgen's cradle (fig. 93) is also highly recommended for compound 
fractures of the thigh. It is made of four wooden bars diverging from 

1 Surgery, 3d Am. edition, p. 848. 



TREATMENT OF FRACTURES 



167 



a foot-piece and supported by a cross-piece at the knee. The limb rests 
upon bands which pass from one upper bar to the other, and are adjust- 



Fie. 92. 







Hodgen's splint. 



able at different lengths by pinning, or by knotting, to meet the varying 
size of the limb. Permanent extension by India-rubber, or by a weight 



Fis. 93. 




Hodgen's cradle 
Fig. 94. 




Hodden's cradle with, extension. 



and pulley, can be used with it (fig. 94). (For adjustment of this 
method of extension see page 180.) 



168 TREATMENT OF FRACTURES. 

Splints made of plaster of Paris are sometimes used for suspension. 
Posterior ones are supported by bands ; anterior ones by cords attached 
to hooks, or wires imbedded in the plaster. Their construction will be 
described subsequently. 

31algaigne's point (fig. 95) is used in fractures of the leg to over- 
come the strong tendency which sometimes exists in the upper fragment 

Fig. 95. 



Malgaigue's point. 



to project anteriorly. Malgaigne found that an iron pin forced through 
the skin into contact with the bone was well tolerated, giving rise to lit- 
tle or no pain or inflammation. Fig. 96 represents the instrument in 
place. In one case in which he used it a fatal erysipelas originated at 



Fi£ 




Malgaigne's point applied. 

the wound, and this fact has brought some discredit upon the method, 
which, moreover, does not commend itself readily to the patient. It 
meets the indication very well, and I should not hesitate to use it in any 
case where the displaced end of the bone threatened to cause perforation 
and could not be otherwise reduced. It has been sought to obtain the 
same result by means of local pressure with a pair of padded rods, 
changing the pressure frequently from one to the other, so as to avoid 
sloughing at the points pressed upon. Fig. 97 represents such an appa- 
ratus ; but experience has shown that they are generally inefficient, 
because, notwithstanding the alternation, the skin is usually unable to 
bear the irritation. In fact, Malgaigne's point Avas devised as a sub- 
stitute for the other. 



TREATMENT OF FRACTURES 



169 



Fig. 97. 




Anger's apparatus for alternate pressure. 

Malgaigne' s hooks (fig. 98) are designed to hold the fragments of a 
broken patella together. They are a pair of hooks united by a movable 



Fig. 98. 



Fig. 99. 





Levis's modification in place. 



Malgaigne's hooks. 

screw. The points of one pair are forced through 
the skin and engaged in the upper fragment, 
those of the other in like manner in the lower, 
and the two are then joined and brought together 
by the screw. Vallette substitutes for the hooks 
a pair of forks attached by movable screws and 
rods to a gutter in which the limb lies ; and Levis 
prefers two separate sets of hooks (fig. 99), 
because they allow a more accurate adjustment 
to the irregularities of the bone. 

Moulded splints are constructed of any material that can be made 
temporarily soft enough to take accurately the shape of the part to 
which it is to be fitted, and which then becomes and remains hard enough 
to retain the shape that has been thus given to it. The materials most 
frequently used are pasteboard, leather, felt, gutta-percha, and plaster 
of Paris. 

Pasteboard or binder's board owes its availability to its quality of 
softening when placed in hot water, and of regaining its stiffness when 
it becomes dry. One or two strips, according to circumstances, are cut 
after a pattern made in paper, placed for a moment in hot water, moulded 
carefully to the limb, and secured in place by lateral splints and a roller 



170 TREATMENT OF FRACTURES. 

bandage until dry. When it is necessary to mould pasteboard at a right 
angle, as at the shoulder, longitudinal slits should be made in it, or 
V-shaped pieces taken out, since creases diminish the stiffness and make 
the pressure of the bandage uneven by their varying thickness. Care 
must be taken not to make the pasteboard too soft, for it then tears 
easily and, by losing some of its starch, becomes unable to regain its 
original stiffness. The details of its application, in a fracture of the leg, 
for example, are as follows : A pattern is made in paper of the lateral 
half of the leg and foot, and two strips of pasteboard cut according to 
it, of such dimensions that when fitted to the limb they cover the sides, 
but do not quite touch each other in front and behind. Reduction is 
then made, and the limb surrounded with a loose bandage, preferably of 
flannel, or with a thin layer of cotton batting ; the two splints, softened 
by immersion in hot w T ater, are placed one on each side and moulded ap- 
proximately to the leg and foot by gentle pressure with the hands, and 
then a roller bandage is snugly applied over them from the toes upward. 
This makes the fit accurate and close. Lateral wooden splints properly 
padded are placed on the sides and secured by bands or a roller band- 
age. Additional security is given by rolling up these lateral splints in 
a broad sheet of cotton cloth, as in the Scultetus bandage, the portion of 
the sheet between them passing under the limb. The pasteboard becomes 
dry in twenty-four hours, and then the lateral splints may be discarded. 

Moulded splints of leather, felt, or cloth stiffened with shellac are pre- 
pared and adjusted in like manner. Those stiffened with shellac can be 
softened by dry heat, but they become flexible only at a comparatively 
high temperature, and stiffen rapidly in cooling. It is therefore neces- 
sary to protect the limb against the heat by compresses or padding, and 
to make the adjustment rapidly. 

Gutta-percha is used in sheets or strips of the same length and breadth 
as the other materials, and from one-sixteenth to one-fourth of an inch in 
thickness, according to the size of the broken bone. It is softened by 
immersion in hot water, and Dr. Hamilton recommends that a large tray 
should be used for this purpose, in which the gutta-percha can be placed 
wrapped in a sheet of muslin. It becomes sticky as it softens and ad- 
heres to the muslin, which then serves to protect the hands of the sur- 
geon and the skin of the limb. If too hot and soft it must be slightly 
chilled by sprinkling it with cold water, and then rapidly moulded upon 
the limb. It hardens in fifteen or twenty minutes, and the process may 
be hastened by sponging it with cold water. 

Plaster of Paris or gypsum was first employed in Western Europe 
in the treatment of fractures early in the present century, having then 
been introduced from Turkey, where it seems to have been in use for a 
long time. It was used to make a solid mould about the limb by placing 
the latter, well-oiled previously, in a box and pouring in enough plaster 
to cover either the limb entirely or only its posterior two-thirds. The 
method was objectionable on so many accounts that its use never became 
general, and it was only after the introduction in 1852 and 1853 by the 
Holland army surgeons Mathysen and Van Loo of the method of applying 
it by means of bandages soaked in the cream that its availability and 
usefulness became apparent, and it earned the favor in which it is now 



TREATMENT OF FRACTURES. 171 

so widely held. It is used now in the form of anterior, posterior, and 
lateral splints moulded accurately to the limb, or as a complete encase- 
ment in simple fractures, and as a fenestrated or interrupted dressing 
strengthened by iron rods or bands in compound fractures. 

The application is usually made in one of two manners : either roller 
bandages of coarse cotton, or preferably of the thin open-meshed mate- 
rial known in commerce as crinoline, are filled Avith the dry powder 
and moistened when needed by immersion in water ; or bands or sheets 
of the same materials or of coarse flannel are soaked in plaster cream 
and then applied to the limb. The former method is used for complete 
encasement or interrupted dressings, the latter for moulded splints. The 
plaster should be fresh and perfectly dry, for if it has been so exposed 
as to absorb a certain amount of moisture from the air it is slow, or may 
fail entirely, to harden. Plaster damaged in this manner can be restored 
by thorough drying in an oven or over a fire. Roller bandages are 
prepared by unrolling them, rubbing the dry plaster thoroughly into 
their meshes, and re-rolling them ; if not to be used immediately, they 
can be preserved for a long time unchanged by wrapping them in oiled 
paper or by keeping them in a closely covered tin box. When needed for 
use, they should be placed on end in water deep enough to cover them, and 
gently pressed to force out the air ; on removal the excess of water 
should be squeezed out. Plaster cream is prepared by placing the quan- 
tity of water judged necessary in a basin and slowly sifting the dry 
plaster in until the mass reaches the surface. It should not be stirred, 
for stirring hastens the "setting." If it is desired to delay the setting 
beyond the usual time, a pinch of cream of tartar may be added to the 
water, or a little gelatine, two or three parts to a thousand of water. The 
addition of common salt or the use of hot w T ater hastens the setting. 

Moulded plaster splints are best made of from eight to fifteen thicknesses 
of crinoline folded to form a rectangle of suitable size or cut to the de- 
sired shape. Before being placed in the plaster cream they should be 
dipped in water and thoroughly wrung out ; then they are partly un- 
folded, or, if made of separate pieces, divided into portions of two or 
three pieces each, passed through the cream, which is well rubbed into 
them, or the cream applied with a spoon, refolded or replaced together, 
stripped down between the hands to remove the superfluous water, and 
applied to the limb directly or with an intervening compress. At 
points where the splints need to be bent at a considerable angle, as at 
the heel, elbow, or shoulder, they should be cut partly through in the 
line that would be taken by the folds if they were not cut, and the edges 
of the cut interlaced. It is well to make the cuts in the different layers in 
lines that do not exactly correspond with each other, in order that the sub- 
sequent union may be more uniform and solid. A simple fold at such a 
point diminishes the solidity of the splint. The application of a dry rol- 
ler bandage outside the splint insures retention of the shape and hastens 
the setting. If there is any tendency to displacement of the bone, reduc- 
tion must be maintained by the hands until the hardening is complete. 

Splints thus prepared may be made impervious to water by brushing 
them over several times with shellac varnish or by pouring melted par- 
affine upon them ; the varnish and the paraffine, if sufficiently hot, will 



172 



TREATMENT OF FRACTURES 



Fig. 100. 



soak through the entire thickness of the splint and protect it perfectly 
from subsequent shortening ; or the splint may be removed and the par- 
affine applied on the inside as well as on the outside. This precaution is 
very desirable when the fracture is complicated by a suppurating wound 
in order to preserve the solidity of the splint and avoid the necessity of 
changing it on account of its saturation with the decomposing discharges. 
Another, but inferior, method is to place a piece of oil-silk between the 
limb and the splint and reflect it over the edge of the latter. 

The splints may be anterior, posterior, or lateral, and the former may 
be readily fitted for suspension by imbedding in them hooks, or stout 
telegraph wire bent to form projecting loops at convenient distances. 

They may also be made somewhat lighter 
without loss of strength by placing thin 
strips of tin, wood, or iron longitudinally 
between their folds, and omitting some 
of the layers of the cloth. The posterior 
splint (fig. 100), combined with a single 
or double lateral one, is very serviceable 
in fractures of the lower end of the leg; 
the posterior splint should be long enough 
to reach from an inch above the toes 
around the heel nearly to the knee, or 
better, perhaps, three or four inches 
above it ; and the lateral one should be 
wrapped first about the instep and then 
carried up the leg to the same height as 
the other, or it may be double, passing 
under the instep like a stirrup. The 
projection of the posterior splint beyond 
the toes serves to keep the weight of the 
bed clothing from them. MacCormac 
recommends a combination of anterior 
and posterior splints for fractures of the 
leg, either simple or compound. The 
shape of the splints and the appearance 
of the limb when thus dressed are shown 
in figs. 101 and 102. The splints must be narrow enough not to come 
into contact with each other at their edges. 

The Bavarian, book-back, or bivalve plaster splint (fig. 103), is 
designed to afford a convenient means of inspecting the broken limb 
during the treatment. It is made of two pieces of coarse flannel that 
has been shrunk and cut of the proper length and of a width somewhat 
greater than the circumference of the limb. These pieces are then 
fastened together by two rows of stitching about half an inch apart 
along the centre, which, in the case of the leg, is to occupy the posterior 
median line, and placed in position under the limb. The one that is 
next to the leg is then folded around it and its free edges stitched 
together in front and along the dorsum and sole of the foot, plaster 
cream is spread smoothly over it and well rubbed in, and the outer layer 
of flannel then drawn over and stitched or pinned fast in like manner. 




Posterior gypsum splint or gutter. 



TREATMENT OF FRACTURES. 



1T3 



After the plaster has set the stitches are cut, the excess of flannel cut 
away, and the edges bound by stitching those of each side together, or 



Fisr. 101. 




Strips to form anterior and posterior plaster splints for the leg. 
Fig. 102. 




The above applied. A, is a -wire bent into loops for the purpose of suspension. 

by binding on strips of leather provided with eyelets. The bandage is 
kept in place by a bandage or by a cord passed through the eyelets, and 

Fiar. 103. 




The Bavarian splint. 



can be readily removed, or one side can be lowered by turning it on the 
hinge which is formed by the narrow strip left between the two rows of 



174 TREATMENT OF FRACTURES. 

stitching behind. Mr. Bryant uses instead of plaster a mixture of preci- 
pitated chalk and mucilage of gum acacia. 

Zsigmondi, 1 of Vienna, recommends a splint made of a flat bag of the 
proper shape and filled with dry plaster. The bag is made of two pieces, 
one of cotton arid one of shrunk flannel, sewed together with an inter- 
posed piece of muslin of the same size. The two pouches of the sac are 
then filled with dry plaster spread evenly through them, and the whole 
dipped into warm water. The air escapes through a small opening left 
at the end where the plaster was introduced, aided by gentle pressure 
with the hands. The sac is removed from the water, allowed to drain 
for a moment, laid upon a table and pressed out evenly, then applied to 
the limb with the flannel next the skin, and fastened with a roller band- 
age. Angles in the limb are provided for by previously cutting out 
V-shaped pieces at the corresponding points in the sac and sewing the 
sides of the gap together, flannel to flannel, and cotton to- cotton. 

Complete encasement of a limb in plaster of Paris (fig. 104), the dress- 
ing that is generally meant when the expression " treatment by plaster of 

Fig. 104. 




Encasement of the leg in plaster of Paris. 

Paris " is used with reference to a fracture, is a dressing of great value. 
Introduced as a substitute for the starch and other " immovable " dress- 
ings, it inherited both their favor and disfavor, but by its general superi- 
ority to them and by the ease with which it lends itself to the treatment 
of compound fractures and operations upon the joints it has established 
its position, and is now in very general use, at one period or another of 
the treatment, although it has suffered somewhat from the exaggerated 
claims of its extreme partisans. The mode of application is as follows : 
after reduction of the displacement by extension the limb is enveloped in 
a sheet of coarse blanketing cut to fit it accurately, or by short roller 
bandages of the same or a similar material loosely applied, or, still bet- 
ter in my opinion, in a layer of cotton batting reinforced over the de- 
pressions and about the bony prominences and supported by a few turns 
of a roller bandage. Then the roller bandages, prepared as above de- 
scribed (p. 171), are applied in the usual manner from below upwards until 
a sufficient thickness has been obtained. They must be simply rolled 
around the limb, not drawn tightly. The limb meanwhile is supported 
and extension maintained by assistants, the bands are rubbed smooth by 
the surgeon, strips of thin wood or metal interposed at intervals to in- 
crease its strength, if necessary, or a wire for suspension, and when 

1 Bulletins de La Societe de Chivurgie, 1878, p. 653. 



TREATMENT OF FRACTURES 



175 



the dressing is completed the limb is lowered upon the bed and the ex- 
tension maintained until the plaster has set. In fracture of the leg or 
thigh the comfort of the patient can be increased by the use of Volk- 
mann's sliding rest for the foot. (See page 182.) 

In the lack of prepared roller bandages, or of the material spoken of 
as most fit for their construction, the dressing can be made of layers of 
any coarse cloth, as shown in fig. 105, _,. nA _ 

and soaked in plaster cream. 

A properly applied dressing should not 
only cause the patient no pain, but should 
produce even a feeling of relative comfort. 
Some sensitiveness may persist for a short 
time at the seat of fracture, but if it has 
not disappeared or become much less by 
the following day the cause should be 
sought for. If this seems to be tightness 
of the dressing, if the circulation in the 
exposed fingers or toes is interfered with, 
as shown by change of color, oedema, or 
loss of sensation, the dressing must be 
removed, or at least laid open longitudi- 
nally, to relieve the pressure and allow 
inspection. 

In fractures complicated by suppura- 
ting wounds fenestrse must be cut, which 
can be done with a sharp knife without 
much trouble, and the edges protected by 
shellac or paraffine. In order also to pre- 
vent saturation by the discharges of the 
cotton or blanketing that lies next the 
skin two or three pieces of oil-silk consid- 
erably larger than the wound should be 
placed upon it, and then, after the fenes- 
tra has been made, slit in different directions, turned out over the edge, 
and fastened down with varnish or collodion. If the wound is to be 
dressed antiseptically, or if the injury is severe and burrowing of the pus 
is feared, a fenestra of sufficient size would weaken the splint too much, 
unless its place were supplied by other means, and therefore bent rods or 
bands of hoop-iron must be imbedded in the dressing during its applica- 
tion, so as to bridge over the opening. These "interrupted" splints 
(figs. 106 and 107) are of many forms, and aiford opportunities for the 
exercise of much ingenuity and skill in their construction. The connect- 
ing rods should be stout, and if bands are used they should be so placed 
that their breadth, and not their thickness, shall be opposed to the expected 
strain. It is usually necessary therefore to have at least two of the latter, 
placed in planes that cross each other at or nearly at a right angle. A 
broad, stout posterior splint of iron imbedded in the plaster, and not 
bent like the others, gives much additional strength (fig. 107). 

Similar fixed dressings are made with starch, dextrine, and silicate of 
soda or potash. Their principle is the same, and each has its own spe- 




Plaster-of-Paris dressiug made of coarse 
sack cloth. (Esmarch.) 



176 



TREATMENT OF FRACTURES. 



cial advantages and disadvantages. The starch bandage, generally 
known in literature as Seutin's, and antedating the others, is made by 



Fia:. 106. 




Fenestrated plaster dressing. 

wrapping the limb in a roller bandage after protecting the bony promi- 
nences with cotton, and then applying numerous rollers saturated with 



Fie. 107. 




Interrupted plaster dressing. A, the straight posterior iron splint. 

starch, and having longitudinal and spiral strips of pasteboard interposed 
between the layers. It requires about forty-eight hours to harden com- 
pletely, and during this time the reduction must be maintained by appro- 
priate external splints. After hardening, the dressing is divided longi- 
tudinally and refastened with a bandage if it is found to fit properly, 
relaxed if too tight, or made tighter if too loose, by cutting out a strip 
along the line of section. The substitution of a tolerably thick layer of 
cotton batting for the first roller bandage is a valuable modification. 
Dextrine was substituted for the starch by Velpeau, because it hardens 
more rapidly, within a few hours. It is obtained in the form of a pow- 
der, which must be prepared for use by mixing it first with alcohol, and 
then reducing it with hot w r ater to the proper consistency. Roller band- 
ages are then unrolled and re-rolled in it, squeezed thoroughly, and applied 
to the limb in the usual manner over a dry bandage or a layer of cotton. 
I have found it more troublesome to use than plaster, and quite as 
objectionable on the score of uncleanliness ; its superiority to plaster is 
in its lightness. 



TREATMENT OF FRACTURES. ITT 

Silicate of soda or potash (water glass) hardens more quickly than 
dextrine, is equally light, and is ready for use in the form in which it is 
obtained. It is a clear, slightly amber-colored, syrupy liquid, with 
which the roller bandages are saturated in the same manner as with 
dextrine ; it is less rigid than plaster, and it has occasionally happened 
that extensive sloughing has been caused by its contact with the skin. 

Quite recently Von Langenbeck 1 has recommended a new cement, 
known as tripolith, as a substitute for plaster. He claims for it that it 
remains unaffected by the air, while in the condition of powder, for a 
longer time than plaster, that it is 14 per cent, lighter, hardens more 
rapidly, is a trifle cheaper, and w T hen once hard and dry is impervious 
to water. It is applied in the same manner as plaster. Its composition 
is a secret, and it is manufactured for use in stucco work. I do not 
know if it can be obtained in this country. 

The advantages of the plaster dressing, as compared with the other 
immovable ones, excepting tripolith of which I have no experience, are : 
1st, that it hardens so rapidly that reduction can be easily maintained 
for the necessary length of time without the aid of splints ; 2d, that it is, 
on the whole, more solid, and therefore better able to prevent subsequent 
displacement ; 3d, that it is sufficiently porous to allow some ventilation of 
the limb ; 4th, that it is simple and cheap. Its disadvantages are its 
w T eight, its destructibility by water, and the impossibility of removing it 
temporarily. If such removal is required a new dressing must be made, 
or the original one must be made in the form of two or more splints, as 
above described. It ought to be unnecessary to add that it can yield no 
better result in the way of shortening than can be obtained at the time 
of the reduction ; the most that it can do is, of course, to preserve the 
length that exists at the time it is applied, but in the controversies to 
which it has given rise this fact seems to have been lost sight of occa- 
sionally on both sides, and the relative merit of the dressing has been 
judged by the results found at the end of treatment, without considera- 
tion of the characteristics of the recent fracture. Its efficiency depends 
also in great part upon the existence of suitable points for counter-pres- 
sure ; the mere encasement of a limb in plaster will not prevent shorten- 
ing if the limb can move longitudinally within its case ; the soft parts 
cannot be depended upon to prevent this motion, because they shrink 
somewhat during the treatment, and the limb lies loosely within the 
dressing. Bony points or surfaces inclined at an angle to the longitudi- 
nal axis on each side of the fracture are alone sufficient, and these can- 
not always be found, or made use of. For this reason, while the dress- 
ing is excellent for fracture of the leg, it cannot be depended upon with 
certainty in fracture of the thigh or of the humerus, because in both 
these cases it is difficult to obtain an upper fixed point, and I therefore 
prefer to postpone its application in a fracture of the thigh until after 
the third or fourth week, when the partial consolidation of the callus 
aids to prevent shortening. Some surgeons, however, use the immova- 
ble apparatus, either of starch or plaster, in all simple cases of fracture 
of the thigh from the very beginning, and do not keep the patient in bed 

1 Berlin. Klinischer Wochenschrift, 1880, No. 46. 
12 



178 TREATMENT OF FRACTURES. 

for more than three or four days. Erichsen 1 says he has treated many 
in this way " and without the slightest shortening or deformity being 
left. The points to he especially attended to are, that the back paste- 
board splint (in the starch dressing) be very strong, at the upper part 
especially, and that the spica be well and firmly applied, so that the hip 
and the whole of the pelvis may be immovably fixed." 

The liability to gangrene, general or local, due to its use, has, I think, 
been overestimated in consequence of a few unfortunate cases, in some 
of which, even, the real agency has perhaps not been recognized. I 
have known the perineum to slough deeply in consequence of the pres- 
sure made upon it by the edge of a dressing applied for a fracture of 
the femur, and that is an illustration of the difficulty just mentioned of 
finding an upper fixed point in such cases, and I have treated a fracture 
of the leg that had become compound by the sloughing of the skin under 
the plaster, but in this case the sloughing was attributed to the coexist- 
ing contusion rather than to undue pressure made by the splint, and from 
what I could learn of the conditions I am inclined to think it would have 
occurred if the fracture had been treated in any other manner. In 
short, it is blind partisanship that claims for plaster success under all 
circumstances, and it is equally blind prejudice that holds it responsible 
for all complications that arise under it. Like any other dressing, it 
must be used judiciously and not in a routine manner, and its limitations 
as well as its merits must be recognized. I should hesitate to apply it 
immediately after the accident if the patient could not be frequently 
seen during the next forty-eight hours, and although the cotton or 
blanketing placed under it is, in the immense majority of cases, a per- 
fectly efficient precaution against excessive local pressure, yet it must be 
remembered that extensive slouching has occurred under such circum- 
stances and is inexplicable on any other theory than that of pressure 
except by resort to unsubstantiated suppositions of nerve injury. It is 
well known that early reduction and perfect retention diminish mate- 
rially the subsequent inflammatory processes, and therefore, since the 
plaster dressing is in suitable cases the most efficient means of retention, 
it should be applied at the earliest possible moment, and as the only 
danger is that of undue pressure, watchfulness ought to be a sufficient 
protection. The interposition of a thick layer of cotton is an absolute 
guarantee against this danger but diminishes the accuracy of the re- 
tention. 

Gurli 2 recommends the immediate application of the plaster very 
strongly on the ground that, so far from causing gangrene, it acts as a 
most efficient antiphlogistic by virtue of the equable pressure which it 
exerts, as well as by its immobility. He recognizes certain exceptions 
in which the dressing must be used with caution, if not entirely rejected. 
These are : present or impending gangrene ; extravasation of blood suf- 
ficient to stretch the skin notably ; injury of a large artery, making the 
formation of a false traumatic aneurism probable ; and, finally, the ex- 
istence of acute erysipelatous or phlegmonous inflammation. 

1 Science and Art of Surgery, Am. ed. 1873, vol. i. p. 377. 

2 Loc cit. 7 vol. i. p. 472. 



TREATMENT OF FRACTURES. 179 

It has been alleged, that failures of union are more common in frac- 
tures treated with plaster, but the allegation appears to be unfounded. 

The double-inclined plane (fig. 108) is designed to maintain reduction 
after fracture of the femur by continuous extension supplied by the 
weight of the pelvis. It consists essentially of two posterior splints, femo- 
ral and tibial, united by a hinge at the knee, and kept at the chosen 

Fig. 108. 




Esmarch's double-inclined plane. 

angle by a horizontal plank upon which it rests, or by a rod, or by straps, 
or by suspension of the tibial portion. The limb rests on cushions placed 
upon the splint and is fastened to it by bandages or by lateral pegs in- 
serted vertically. It is essential that the femoral splint and the hori- 
zontal plank shall not support the pelvis ; this must be left free to sink 
into the mattress and thus furnish the desired extension. Mayor modi- 
fied this apparatus by making it of wire and broad enough to bear both 
limbs, using the uninjured one as a sort of splint to secure the other in 
a good position. Mr. Bryant says he has found it very valuable in frac- 
tures of the upper third of the femur where the upper fragment is apt to 
tilt forward and rotate outwards, but it should be used only when other 
means fail, and it is daily dropping out of use. 

The treatment of fractures by continuous extension applied to the 
distal segment of the limb has been in use for centuries, the means em- 
ployed being a weight and pulley or an adjustable screw passing through 
the foot piece of a long splint in fractures of the thigh, for example. 
Counter-extension was maintained by a perineal band attached to the 
head of the bed in the former case, and to the upper end of the long 
splint in the latter. The disadvantages were serious ; if the extension 
was efficient the pressure produced upon the dorsum of the foot and 
about the ankles by the bands through which it was made caused pain 
and, if prolonged, sloughing ; if moderate enough not to cause this 
result it was insufficient to prevent shortening, and the surgeon's time 
was spent in alternately increasing and diminishing the traction to meet 
first one and then the other indication. The patient too often found his 
convalescence retarded by a slough and his limb permanently shorter by 
one or two inches. 

The first important modification was the substitution of long strips of 
adhesive plaster for the bands and girdles by which the weight or the 
screw was attached to the limb. This device entirely prevents pain and 
eschars, and allows the use of a traction of twenty or twenty-five pounds 



180 TREATMENT OF FRACTURES. 

without serious inconvenience to the patient. It appears to have been first 1 
employed not infrequently in Pennsylvania before 1848, and published 
by Sargent 2 at that date, and again independently by Dr. Josiah Crosby, 
who published it in the Transactions of the American Medical Associa- 
tion in 1850 (vol. iii. p. 382), but its popularization seems to have been 
due to Dr. Gurdon Buck, who introduced it on Dr. Crosby's suggestion 
into the N. Y. Hospital before 1852. In 1855, a specimen of the thigh 
splint as then used in the N. Y. Hospital was given by the late Dr. 
Suckley to Nelaton, and another was taken at the same time by Prof. 
C. R. Agnew to Dublin. 3 This was its introduction into Europe, and 
this method of making extension is frequently spoken of in foreign works 
as the " American method " of treating fractures. 

The next step in the development of the dressing here in America was 
the adoption of short coaptation splints and the discarding of the long 
splint and of the perineal band, and reliance upon the weight and pulley 
for extension, and upon the elevation of the foot of the bed to make counter- 
extension by the weight of the body sufficient. The raising of the foot 
of the bed was suggested by Dr. Van Ingen., of Schenectady, N. Y., in 
1857, 4 and, like the extension by adhesive plaster, was adopted and 
popularized by Dr. Buck. Dr. Hamilton still uses the long splint with 
a cross-piece at the foot to prevent rotation (fig. 113), but Volkmann's 
sliding rest (fig. 112) answers the purpose equally well and possesses 
additional advantages of its own. The substitution of an elastic for the 
rigid cord to suspend the weight seems to me of no importance if the 
pulley moves freely. Elasticity in the means of traction is of value 
only when one of the points is fixed ; as it can neither increase nor 
diminish the force exerted by a freely movable weight it adds nothing to 
the constancy or equality of the extension; and if it yields more readily 
than the weight alone would to a sudden twitch of the muscles it may be 
disadvantageous rather than useful by allowing a momentary mobility 
that the weight might prevent. 

In England and in France the long splint has been retained, and the 
extension is made more generally by an India-rubber cord with diverse 
methods of counter-extension than by the weight and pulley. 

The principle of the method of treatment by continuous extension is 
to tire out the muscles whose contraction causes displacement by a 
moderate but persistent strain upon them, one from which they are not 
relieved for several weeks. Its principal and most important use is in 
fractures of the shaft of the femur, but it may be used whenever the in- 
dications exist and a sufficient and suitable surface can be found for the 
attachment of the adhesive plaster, and when proper counter-extension 

1 The use of adhesive plaster by Grooch ahout one hundred years ago, referred to by 
Martin in the North Carolina Medical Journal, January, 1878, and by Prof. Van 
Buren in the N. Y. Medical Record, 1878, p. 242, and quoted by Dr. Hamilton in the 
sixth edition of his work, does not seem to justify the claim to priority made in his 
favor, for he used it, not to make extension in fractures, but only to flex the heel 
upon the leg after rupture of the tendo Achillis, just as it is used to draw together the 
sides of a gaping wound. 

2 Minor Surgery, Phila., 1848, quoted in a note of Crosby's paper. 

3 Van Buren, in N. Y. Medical Record, 1878, p. 241. 

4 Trans. Am. Med. Ass., vol. x. 1857, p. 436 ; quoted by Van Buren, loc. cit. 



TREATMENT OF FRACTURES 



181 



can be made. Such uses will be described in connection with the dif- 
ferent fractures to which they are applicable, and I shall mention here 
only the details of its use in fractures of the thigh. 

A band four or five inches wide of stout moleskin adhesive plaster, 
long enough to reach from a point on the side of the thigh a few inches 
above the knee loosely around the sole of the foot and back to a point 
opposite that at which it began, is notched in its middle portion and slit 
at the ends as shown in figure 109 ; a fiat piece of wood, five by three 

" Fiff. 109. 








inches and perforated in the centre, is secured in the centre of the strip 
by folding the edges of the latter over it, the folds being continued up 
to the notches (fig. 110) so as to cover in the adhesive surface of the 



Fig. 110. 




intermediate portion. The piece of wood must be longer than the dis- 
tance between the malleoli. A roller bandage is then applied to the 
foot, ankle, and lower third of the leg, the plaster placed on the sides 
of the limb above it, the foot-piece being about two inches below the 
sole of the foot, and secured there by carrying the bandage up over it; 
the upper ends of the plaster, if long enough, may be turned down and 
covered by a few additional turns of the roller. It is very desirable 



Fig. 111. 




Adhesive plaster applied for extension. 



that the plaster should be carried above the knee whenever possible, in 
order to avoid the prolonged strain upon the ligaments of the joint that 
is produced when the attachment is to the leg alone, and it is also well 
to pad the ankles with cotton before applying the roller. Short coapta- 
tion splints, usually four in number, or the flexible wooden, Gooch's, 
splints are strapped upon the thigh, the cord attached to the foot-piece 
by passing it through the central hole and knotting it on the inside, 



182 



TREATMENT OF FRACTURES 



carried over a pulley fastened to the foot of the bed, and made fast to 
the weights. Finally, the foot of the bed is raised six or eight inches, 
and the leg placed upon a Yolkmann's sliding rest. 

A^olkmann's sliding rest (fig. 112) is composed of a wooden frame, 
the side bars of which are triangular with an upper edge upon which 



Fig. 112. 




Volkmann's sliding rest for fractures of the thigh. 

two cross-bars rest. To these cross-bars are fixed a posterior splint 
and an upright foot-piece, the former cut away centrally in its lower quar- 

Fiff. 113. 




Long side splint. (Hamilton.) 



ter to accommodate the heel. The foot and leg are fastened to the 
splint by a roller bandage, and can thus be moved freely up and down 
the bed, the cross-bars which support them sliding without much friction 
upon the triangular side-pieces. This apparatus adds much to the com- 
fort of the patient, and moreover prevents rotation of the leg. It takes 
the place of the long side-splint and cross-bar (fig. 113). 



TREATMENT OF FRACTURES 



183 



Elastic extension without a weight and pulley is accomplished by 
means of stout India-rubber tubing attached to the leg by adhesive plas- 
ter as above described and to a long side-splint extending well up toward 
the axilla. Counter-extension is made by a perineal band fastened to 
the upper end of the splint, or by a band of stout cloth carefully fitted to 
the upper portion of the opposite thigh and carried, one end in front, the 
other behind the body, to the top of the splint, or by a cord attached to 
the end of a rod extending from the upper end of the splint in front of 
and well beyond the shoulder, and fastened by bands of adhesive plaster 
to the abdomen and back, or, finally, by bandaging the other thigh and 
leg securely to a second side-splint which is attached to the first by a 

Fig. 114. 




Indiaralher' 
Accumulator' 

Permanent extension by India-rubber. 



cross-piece at the foot and by a pelvic bandage or brace. Figs. 114, 
115, and 116 represent forms in common use. Mr. Bryant prefers the 



one shown in fig. 114. 



Fig. 115. 

Double ,'zidky 




IncLRubberAcwmulator 



Cripp's splint. 
Fig. 116. 




Roji c w i th Cc- n t- fasten er for 
Extension of affected limb 



Indict rubber 

Accumulator 



Campbell de Morgan's splint. 



The relative merits of, and the special indications for, these different 
methods of treating simple fractures have, I trust, been sufficently set 
forth in the preceding pages from the general stand-point to render a 
detailed comparison and judgment unnecessary at this time. They will 
be again referred to in connection with the special fractures or conditions 
to which each may be particularly appropriate. 



184 TREATMENT OF FRACTURES. 

A plaster dressing that has been applied after complete reduction, and 
under which all seems to be doing well, may be left unchanged until the 
expiration of the period usually sufficient for complete consolidation, the 
length of which varies with the age of the patient and the size of the 
bone. If, however, it is found to have become so loose by the shrinking 
of the limb as to afford apparently inadequate support, it should be re- 
moved and a new one applied, the opportunity being improved to correct, 
if possible, any displacement or faulty position that may have occurred 
under it. Other dressings require a more frequent examination in the 
later as well as in the earlier periods of the treatment, for displacements, 
especially the angular ones, may occur as late as the third, or even the 
fifth week, and then if not promptly detected may soon become irremedia- 
ble except by operation. In addition to the more thorough examination 
which is here referred to, one requiring more or less complete removal 
of the splints, frequent inspection without disturbance is required to de- 
tect change of position or the occurrence of any complication. Especial 
attention must be paid in the treatment of fracture of the upper portion 
of the leg or of the thigh to the detection and correction of outward ro- 
tation of the upper fragment, which is produced by the sinking of that 
side of the pelvis while the dressing keeps the lower fragment from 
sharing in the rotation. I have found this tendency very troublesome 
after excision of the knee, even when the leg and thigh were incased in 
plaster, and it has been pointed out by Gosselin in fractures of the leg. 

The opportunity afforded by a change of the dressing may be im- 
proved to communicate gentle movements to contiguous joints that have 
been immobilized but not involved in the fracture*, or to reapply the 
dressing with the limb in a different position. Opinions are divided 
upon the propriety of communicating movements to fractured joints, 
some surgeons preferring to maintain absolute immobility until con- 
solidation is complete, others communicating motion at regular and 
short intervals after consolidation is well begun, and others, again, using 
from the first dressings that support but do not immobilize, as a sling in 
fracture of the elbow. A notable discussion upon this point was raised 
in 1879 in the Societe de Chirurgie by Verneuil, himself an advocate of 
complete immobilization, and carried on during several sessions. No 
formal conclusions were reached, but the weight of testimony was in 
favor of immobility. Verneuil's argument was that the stiffness of a 
joint is the result of its inflammation, not of its immobility, and that im- 
mobility, being the best possible antiphlogistic under the circumstances, 
would diminish instead of increasing the stiffness. Whatever the sur- 
geon's opinion upon this point may be, it is very certain that he will 
have to be content with immobilization in many cases, because communi- 
cated movements are so painful that patients will not submit to them. 
He must wait until consolidation is complete, and then try to overcome 
the adhesions by regular exercise or by breaking them up under anaes- 
thesia. 

The same question arises, but is less serious, in the management of 
large joints adjoining a fracture of the shaft of a long bone. As has 
been shown, they may be affected by an arthritis due to a concomitant 
sprain, to extension, or to the spread of the inflammatory process set up 



TREATMENT OF FRACTURES. 185 

about the fracture, but the severity of this arthritis is seldom great, and its 
consequences not permanent except in the old and individuals constitution- 
ally predisposed to arthritic troubles. Immobilization may be safely em- 
ployed for several weeks, and it is exceptional to see a resulting stiffness 
that does not yield to moderate and natural exercise. It is desirable to 
hasten its disappearance by daily gentle flexion and extension of the 
limb as soon as the consolidation is sufficiently advanced to allow this to 
be done without danger of causing pseudarthrosis, and if the manipula- 
tions do not make the joint hot and tender. 

In the smaller joints of the hand the case is different. There the ex- 
tended position and immobility favor stiffening, even when the fracture 
involves only the forearm or arm, and therefore they should be left free, 
or dressed in the flexed position and moved every day. 

Local measures to prevent or reduce inflammation about a simple frac- 
ture are rarely called for, and are generally restricted to some cooling 
lotion scantily used so as not to wet the permanent dressing, lead and 
opium, and the ice-bag. The latter must be used cautiously because of 
the risk of causing local sloughs, or, according to some authors, of retard- 
ing the repair of the fracture. The blisters which appear so frequently 
on the surface of the limb need only to be pricked and protected from 
chafing by adhesive plaster or flexible collodion. 

Medicinal treatment is directed only to the general condition of the 
patient and guided by such indications as may arise. Phosphate of lime 
is occasionally given with the idea that it favors the consolidation of the 
callus by supplying the needed earthy matters, and some cases and experi- 
ments have been published as demonstrative of benefit obtained by its 
use. It is doubtful, however, if it has any such specific action, or any 
value except as an antacid and absorbent. It is furnished in sufficient 
quantity in ordinary food, and any excess is rapidly eliminated through 
the kidneys. 1 

Compound Fractures. 

The treatment of compound fractures comprises two indications : the 
repair of the fracture, and the healing of the wound. The first is met 
in the same manner as after simple fracture, by reduction and retention, 
the means employed varying only so far as is necessary to make them 
compatible with the proper treatment of the wound. It is the latter, of 
course, which gives this class of fracture its especial importance and 
dominates the treatment, and which has made compound fractures the 
type of severe surgical injuries and the basis of statistics collected to 
determine the merits of contrasted methods of treating wounds. 

Fractures may be compound from the beginning, or they may become 
so by the occurrence of suppuration, the extension of a coexisting wound, 
or the formation and fall of an eschar. The accepted rule of practice is 
to treat all fractures w T ith contiguous and possibly connecting wounds as 
if they were compound, and to avoid explorations of the wound whose 
sole object would be to determine their communication or non-com- 

1 See Midriu, These de Paris, 1877, No. 96, Du phosphate de chaux dans les frac- 
tures. 



186 TREATMENT OF FRACTURES. 

munication with the fracture. The treatment of eschars due to pressure, 
contusion, or extravasation should be such as to delay their separation, 
if possible, until granulations shall have formed upon the broken surfaces 
of the bone and sealed its canals. Verneuil and Marchand 1 report an 
interesting case of this character, though not associated with fracture ; 
the skin of the thigh, covering an enormous extravasation of blood com- 
ing probably from the ruptured popliteal vein, was contused at several 
points and showed numerous small gray eschars still adherent to the 
underlying parts. These eschars were painted twice a day, sometimes 
with tincture of iodine, sometimes with a solution of perchloride of iron. 
This treatment delayed their separation until the extravasation had been 
almost entirely absorbed.. 

Slight, clean-cut wounds that are capable of healing by primary union, 
especially such as have been caused by the projection of the sharp end 
of a fragment, must be treated with the view of favoring this result, 
and it can often be obtained' by simple measures, such as- the application 
of a suture or an occluding dressins;. A favorite method of the English 
surgeons a century ago, and one which is still occasionally employed, is 
to cover the. wound with a pledget of lint soaked in the patient's blood ; 
if all goes well it dries-, and the wound' heals under it as under a scab. 
Or strips of muslin, gold-beater's skin, oil-silk, or thin rubber tissue 
should be clipped in flexible collodion and laid- obliquely across the 
wound, each strip crossing' the preceding one at right angles and over- 
lapping about one third of the preceding- parallel one, just as a wound is 
strapped with adhesive plaster.- This is a better method than simply 
covering the wound with a square piece of the same material dipped in 
collodion. If serum accumulates under the covering it may be let out 
through a puncture made with a needle, and the opening closed with 
another strip. 

Simply covering tlie wound with a few folds of lint soaked in the com- 
pound tincture of benzoin is said, by Mr. Fergus M. Brown, 2 to have 
yielded good results. He recommends it especially for country practi- 
tioners, who "are at a loss for some remedy for wounds which will 
obviate the necessity of going every day long distances to dress trifling 
injuries." A compound fracture^ however, is not - a trifling injury. 

If the wound is so large or so contused' that primary union is not to 
be hoped for, it should be treated systematically and thoroughly in ac- 
cordance with the modern principles of the treatment of surgical wounds. 
First among the various methods by which these principles are carried 
into practice I place unhesitatingly the Lister, method, and next in order 
the method of " through drainage," introduced by Prof. Markoe, and 
Guerin's cotton dressing, of which latter, however, my experience is 
limited to its use after amputations, excisions of joints, and osteotomies. 

The wound and the fracture require certain attentions before the 
dressing is applied. Reduction must, of course, be made as after simple 
fracture, and this is sometimes made exceptionally difficult by the pres- 
ence of a complication, the projection of a fragment through the skin. 

1 Dictionnaire Encyclopedique des Sciences Medicales, article, Contusion, p. 150. 

2 Lancet, July, 1880, p. 9. 



TREATMENT OF FRACTURES. 187 

If extension and counter-extension, aided by pressing- the skin upwards 
or downwards, do not suffice, the wound must he enlarged. freely and, if 
necessary, the muscles divided under it- This, as a rule, is better than 
cutting off the end of the bone, for the sides of the- incision can be 
brought together again by sutures, and its prompt union may be con- 
fidently expected : under antiseptic, treatment. 

The seat of fracture may also be cautiously explored with the finger 
for the purpose of removing totally detached splinters or foreign bodies. 
Splinters adherent to the soft parts must not be torn away ;. it has 
already been shown (page 121),that they will probably retain* their vital- 
ity and perforata valuable part in the consolidation that is to follow. 

If the tendency to displacement is such that it cannot be successfully 
opposed by the retentive dressings at command, it may occasionally be 
desirable to fasten the ends of the fragments together by a suture or 
ligature. This device 1 ' finds its most common use in. operations for the 
cure of pseudarthrosis, but it is also occasionally used in fractures of the 
long bones,. and quite recently, in the bold extension which the success 
of the Lister dressing has given to operative surgery, has been employed 
even in simple fractures of the patella and olecranon. The most per- 
sistent, if not the earliest, advocate of its systematic use appears to have 
been Lerenger-Feraud, 2; but even he finds it most frequently indicated in 
cases of delayed union. It does not seem probable that its use at an 
eaily period w T ould ever be necessary except in some oblique fractures of 
the tibia or humerus, marked by a strong tendency to displacement. 
After having enlarged the wound, if necessary, and exposed the bone 
the lig ture is- applied by passing it under the fragments with the aid of 
a curved, blunt needle or probe, and then twisting it tightly, if of metal, 
or tying it, if of silk, about them after reduction has been made. The 
suture is applied.' by drilling, small holes at corresponding points in the 
fragments, passing a wire or thread through, and fixing it as before. If 
the fracture is sufficiently oblique the ligature holds the bones more 
firmly than the suture, and is not liable to cut or break out as the latter 
is, but its application is likely to require a more extensive denudation of 
the bone. Another method mentioned by MacCormac s 'is to transfix the 
bones with a needle and apply the wire in a figure of eight about its ends. 

1 Norris (Am„..Journ. Med.. Sciences, January, 1842) has been quoted to the effect 
that Hippocrates practised this in recent fractures, and that Horeau applied the same 
procedure to ununited fracturesdn 1805, hut the quotation is inexact and incomplete. 
Norris says Horeau did not originate the idea ; it was practised before him by Icart, 
who bound the fragments closely together by a metallic ligature tbrown around them. 
Dr. J. Kearny Rodgers, of New York, appears to have been the first (1825) to use 
the suture in ununited fracture of a long bone. Hippocrates only tied the teeth 
together after fracture of the lower jaw. Berenger-Feraud (loc cit. infra), depending 
upon an incorrect translation of Hippocrates, states that he sutured the bones directly, 
but the error has been clearly demonstrated by Letenneur in the Union Medicale, 
1870, p. 949, by the aid of the original text. Littre's translation of the disputed 
phrase (vol. iv. p. 149) reads as follows : "La coaptation opSree, on attache les dents 
ensemble, comme plus haut ; cela contribuera grandemeht a l'immobilite, surtout si 
on sait les attacher regulierement, nouant les bouts des fils comme ils doivent etre 
noues." 

2 Bull, de l'Academie de Medecine, 1865, vol. xxx. ; Gaz. Hebdomadaire, 1867, pp. 
610, 624, and 629 ; and several subsequent papers. 

3 Antiseptic Surgery, 1880, p. 198. 



188 TREATMENT OF FRACTURES. 

By withdrawing the needle the wire is liberated and can then be easily 
removed. Some of the other devices used in pseudarthrosis, such as 
fixation of the fragments by a gimlet, an ivory peg, or an iron nail 
driven through them, might be also employed in recent fracture. 

It is the usual practice to bring out the ends of the wire through the 
wound and to remove it after the lapse of from two. to four weeks by 
untwisting it and drawing upon one end, for although the wire may, 
if cut short, become encysted, yet if it should keep up suppuration its 
removal would then be difficult, or at least more troublesome. 

The Antiseptic (Lister) Method. — Mr. MacCormac 1 says : " In no 
kind of surgical injury have the results accomplished by the antiseptic 
method been more thoroughly satisfactory and complete than in com- 
pound fracture. In future we may expect to save the limb of the pa- 
tient in all cases in which the extent of damage to the soft parts, vessels 
and nerves, is not such as to absolutely forbid the attempt. Even in 
cases where the expectation of saving the limb is not great, we are justi- 
fied in giving the patient the benefit of the doubt, as we do not endanger 
his life by so doing ; and should gangrene or any necessity for operation 
occur, Ave may then amputate without increased risk." 

As this asserted superiority is denied by some, and the denial sup- 
ported by reference to occasional unfavorable results, it seems proper 
that the details employed by the strong partisans of the method, those 
who assert its superiority unequivocally as evidenced by the results they 
obtain, should be fully understood, and I shall therefore give at first the 
rules laid down by MacCormac and Lucas-Championniere, 2 the latter 
being the recognized exponent of the theory and practice in France, and 
then indicate various modifications employed by others. 

The materials needed are carbolized gauze, 3 mackintosh or oil-silk, 
drainage tubes, and two solutions of carbolic acid in water, of the 
strength of 1 in 40 and 1 in 20. The portion of the limb that is to be 
enveloped in the dressing is first well washed with soap and water, and 
then with the stronger solution. An anaesthetic is usually used, because 
the manipnlations are often painful and protracted. 

In cases seen shortly after the receipt of the injury the wound must 
be thoroughly irrigated with the weaker solution ; in those that have 
been exposed for several hours the strong solution is used. If the ex- 
ternal wound is too small to allow complete irrigation, it must be en- 
larged, for this disinfection of the cavity is asserted to be the most 
important part of the practice, and one or more counter-openings may 
need to be made in order that it may be thoroughly well done. For 

1 Antiseptic Surgery, 1880, p. 180. 

2 Chirurgie Antiseptique, 2d ed. Paris, 1880. 

3 If the prepared gauze cannot be obtained it can be made when needed by saturat- 
ing a loose-meshed cotton fabric (cheese-cloth, for example) with Von Brun's solution 
and drying it. This solution is : — 

Carbolic acid, ..... 100 parts 

Castor oil, 80 " 

Alcohol or benzine, . . . 2000 '' 

Resin, . . . . . . 400 " 

The resin is first thoroughly dissolved in the alcohol or benzine, and then the others 
added to it. 100 parts of glycerine may be substituted for the castor oil. 



TREATMENT OF FRACTURES. 189 

this washing a syringe is used, and when the fracture is not well exposed 
the liquid should be injected through a soft rubber catheter, the point of 
which is moved to the different parts of the cavity. When the wound 
cavity is large and has been exposed for some hours before the treat- 
ment is begun, or when foreign bodies have been forced into it, the wash- 
ing must be continued for fifteen or twenty minutes with the strong solu- 
tion ; or a still stronger one, 1 part of carbolic acid in 5 parts of alcohol, 
may be used. Attention must be paid to the free escape of the liquid 
during injection, the cavity must be irrigated, not much distended, and 
the last mentioned solution must be used cautiously and gently, for it is 
caustic. If suppuration has begun and granulations have formed, the 
cavity of the wound should be scraped with a curette, or an eight or 
ten per cent, solution of chloride of zinc may be used first and then 
followed by the carbolic acid. 

In some of the slighter recent cases, as of the leg with perforation of 
the skin by the end of one fragment, it may be proper to try for primary 
union, but as a rule drainage tubes should be used, always when the 
wound is large or unclean, or when the bleeding cannot be completely 
checked. Counter- openings are made to facilitate the first washing and 
the subsequent drainage. It is undesirable to pass the drainage tube 
between the fragments of the bone when this can be avoided, but in the 
cases in which it has been done it does not seem to have caused necrosis 
or to have interfered with union. 

Loose fragments and foreign bodies are removed, but projecting points 
of bone should not be cut away unless they actually interfere with the 
setting of the fracture. 

After the disinfection, arrest of bleeding as far as possible, and inser- 
tion of the drainage tubes, the incisions are brought together with sutures, 
pads of gauze or carbolized jute placed to make pressure and prevent 
burrowing, and the gauze dressing and splints placed over all. The dress- 
ing will probably need to be changed the next day and on the third, on 
account of its saturation with blood or the free serous discharge of the 
first hours, but afterwards it may usually be left in place for several 
days. It is seldom desirable to leave the drainage tubes in for more 
than a week, and as a rule they may be removed whenever the dressing 
has remained unstained for two days. 

I have met with no account of the use of Neuber's bone-drains and 
permanent dressings in compound fracture, but should think the elastic 
pressure he recommends would be as useful in these cases as it is after 
operations. 

The most useful form of retentive apparatus in most instances is the 
plaster splint, so constructed that it can be applied and removed without 
damage to it, or an interrupted plaster dressing. A fenestrated 
plaster case does not give sufficient room for the gauze dressing. A 
convenient form of splint recommended by MacCormac for compound 
fracture of the leg has been already described in connection with figures 
100, 101, and 102. When the wound is on the anterior surface, as it usu- 
ally is, the posterior splint can be easily arranged so as rarely to require 
removal. It should be made comparatively narrow, narrower than that 
shown in figure 100, lined internally with mackintosh or oil-silk, over which 



190 TREATMENT OF FRACTURES. 

is placed a layer of folded carbolized gauze. This is placed directly 
upon the leg, the gauze dressing laid upon the wound, and both secured 
by turns of a roller (fig. 117). The anterior splint is then made and 
fixed with another roller. When the wound is to be dressed the anterior 

Fig. 117. 




Compound fracture. Lister dressing and plaster splint. 

splint and gauze are removed, the leg remaining undisturbed in the pos- 
terior splint, out of which, however, it can be lifted if need be. In like 
manner, when the wound is on the posterior surface the anterior splint is 
the permanent one. 

In my opinion, the use of the spray is not essential to the success of 
this method of treating a wound. The irrigation supplies its place at the 
first dressing, and in the subsequent ones a hand spray may be used, or 
a sponge saturated with the carbolic solution squeezed over the wound 
and the mouth of the tube, or a strip of rriuslin wet with the same solu- 
tion laid over them. Inability to obtain a steam atomizer is therefore, 
in my judgment, not a sufficient reason for not resorting to the method. 

A device suggested and employed successfully by Yerneuil 1 may- be 
used, especially in cases where the wound is small and a drainage tube 
is not considered necessary. After disinfecting the wound and the ad- 
joining surface he covers it with a piece of oil-silk three or four inches 
square fastened to the skin on three sides by collodion ; the dependent 
side is left unattached, and the gauze dressings are applied as usual. 
The blood and secretions of the wound make their way out to the free 
edge of the oil-silk and are there absorbed by the gauze. When the 
dressing is changed the oil-silk is not disturbed, its free edge is washed 
and the new dressing applied. Or if antiseptic gauze is not attainable 
layers of muslin wet with the carbolic solution and covered with cotton 
and oil-silk may be substituted. The small square of oil-silk protects 
the wound from contact with the acid, and healing goes on under it un- 
checked. It should, however, be painted over with collodion to make it 
more resisting, or should be double. 

" The " through drainage" proposed by Prof. Markoe 2 has furnished 
excellent results. It is based upon the theory that the benefits ob- 
tained by the use of carbolic acid are due as much to its topical action 
upon the tissues as to its power of preventing decomposition. The 
method has been extensively and successfully employed at the New York 

1 Memoires de Chirurgie, vol. ii. 1880, p. 271. 

2 Am. Journ. Med. Sciences, April, 1880. 



TREATMENT OF FRACTURES. 191 

and Bellevue Hospitals during the past year and a half (1881). One 
or more counter openings are made, perforated drainage tubes passed, 
and injections of a 2J per cent, solution of carbolic acid in water made 
three or four times daily. The wounds are covered usually with a thick 
layer of antiseptic gauze through which the ends of the tubes project, 
but this is not considered essential, a simple dressing kept wet with car- 
bolic acid being thought sufficient. 

It has been shown, by experiment and clinically, that while the 
contact of carbolic acid with a granulating surface checks suppuration 
it also retards cicatrization, and therefore I prefer to follow the example 
of the pure Listerians and inject the wound only when there is a definite 
reason for so doing, such as putrefaction, excessive suppuration, or in- 
flammation. Still, Prof. Markoe has observed in several cases that the 
injections relieved pain or soreness so markedly that the patients asked 
to have them repeated more frequently. I have heard it charged that 
necrosis was more likely to occur under this than under the Lister treat- 
ment, but have never observed any facts that substantiated the charge. 
I have used it a number of times in old fractures with large freely sup- 
purating cavities and inflamed borders, and in some severe recent ones with 
much oozing, and have always been satisfied with the results. I recall 
one case in particular, a severe compound fracture of the lower third of 
the leg with a projecting fragment and large lacerated Avound. It was first 
seen upon the fourth or fifth day when the patient presented a most un- 
promising outlook, with sub-delirium, a dry tongue, and a temperature 
of 104° ; the limb was much swollen, the wound fetid, and its edges in- 
flamed and boggy for a considerable distance. Drainage tubes were 
passed to either side of the leg and frequent injections made. The 
temperature fell, the wound improved rapidly, and the patient recovered 
without necrosis, although for some time the end of the upper fragment 
was exposed and bare for more than an inch. 

Gruerin , s cotton dressing, which grew rapidly into favor in France in 
1871 in the treatment of amputations and excisions, has been used 
successfully, although more sparingly, in compound fractures. So far 
as can be judged from current publications it now holds a place second 
to the antiseptic method in French hospital practice. The method con- 
sists essentially in the envelopment of the limb in very thick layers of 
cotton batting tightly bound on with a roller bandage and left in place 
for three weeks. The principal objection to it in the treatment of frac- 
tures is the difficulty of securing at the same time efficient contention of 
the fragment. This, however, is of secondary importance when the 
lesions are very grave and the question of amputation is impending ; 
under such conditions the surgeon may be well content to save the limb 
even if its form should be more or less irregular, and, in default of better 
means, the cotton dressing enables him to do this. The thermometer 
may be safely depended upon to give timely notice of complications oc- 
curring about the wound. 

The limb and the wound are first disinfected ; then the entire limb is 
WTapped in successive layers of cotton batting, the thickness of which 
when tightly compressed with a roller bandage is about two inches ; 
reduction is made by extension and counter-extension, and immobility 



192 TREATMENT OF FRACTURES, 

secured by a gypsum, starch, or silicate of soda bandage applied over 
all. Gudrin advises that the uniformity of the compression should be 
further assured by the application of a second roller bandage on the 
second day, and if this is done it must of course precede the hardening 
bandage. 

Verneuil 1 uses a modified form of this dressing which, he claims, as- 
sures a better retention and gives an opportunity for inspection of the 
parts without disturbing the patient. It consists of a Scultetus appa- 
ratus with the addition of an inner layer of broad bands of cotton batting 
corresponding in direction and mode of application to the layer of short 
bands. (See p. lbO.) The thickness of the layer is very much less than 
that of the Guerin dressing, but, according to Verneuil, its efficiency is 
as great. He further covers the wound with a patch of oil-silk as above 
described, and lays over it compresses wet with carbolized water. 

The inflammatory processes that may supervene in the progress of 
the case are met in accordance with the general principles of surgery. 
Pus that has burrowed or formed at a distance must be promptly evacu- 
ated ; it is not necessary to wait for fluctuation when the bogginess and 
tenderness at any point show so clearly what is going on underneath, or 
when a probe can be passed down to the collection through the main 
wound. These abscesses usually communicate with the main cavity, 
and it is desirable that drainage tubes should be passed through from 
one to the other. 

Inflammation about the wound is best controlled, in my experience, by 
the free use of the weaker carbolic solution in frequent injections and 
upon compresses. In fractures of the fingers, hand, or forearm, with 
severe inflammation of the inter-muscular spaces of the latter, I have 
seen much good result from immersion of the limb for several hours in a 
bath of tepid water containing one per cent, of carbolic acid. I usually 
keep it in the bath during the greater part of the day, covering it in 
the intervals and at night with compresses wet with the two and a half 
per cent, solution, and continuing this until the inflammation subsides. 

Prof. Hamilton recommends the use of compresses of sheet lint kept 
constantly wet with water at the temperature of 95° to 100°, or, in 
the case of gangrene, actual or impending, 105° to 110°. 

The use of cold, either by the ice-bag or irrigation, has been recom- 
mended, but the weight of evidence is now against it. Spillmann 2 says 
it is actually harmful in fractures of the arm or thigh, often useful in 
those of the forearm or leg, and " yields marvellous results when applied 
to injuries of the hand or foot." Used upon a badly contused wound it 
will almost certainly cause gangrene In such cases a light well-made 
poultice may sometimes be used with advantage. 

If suppuration is prolonged it may be profuse and undermine the 
patient's strength to such a degree as to render the sacrifice of the limb 
necessary to the preservation of his life ; or it may be slight, the wound 
being reduced to a simple sinus, and the fracture so well consolidated as 
to make the limb useful. Both results are more rare than they were 

1 Loc cit., p. 272. 

2 Diet. Encyclopedique, 4th Series, vol. iv. p. 169. 



TREATMENT OF FRACTURES. 193 

formerly. Sinuses are kept up by caries, necrosis of portions of the 
callus or of splinters, and by foreign bodies introduced at the time the 
fracture was received. When due to caries they may sometimes be 
cured by stimulating injections such as the sulphate of copper or of zinc, 
or Villate's liquid. When due to necrosis or the presence of foreign 
bodies they must be enlarged and the cause removed. This may require 
the cutting away of a portion of the callus, and it should be done thor- 
oughly. The antiseptic method has furnished some rapid and complete 
cures in this class of cases. 

For the treatment of other complications the reader is referred to the 
preceding chapter. 

The same principles and details of treatment, modified somewhat by 
the different anatomical conditions, are applicable to the treatment of 
compound fractures communicating with or involving a large joint. 
The antiseptic method has wrought an even greater change in the treat- 
ment of this variety than in the less complicated ones of the shaft, and 
it is now the rule to save the limb where formerly it was the exception. 
The opening into the joint must be enlarged if necessary, or free incisions 
made to insure thorough disinfection and drainage ; this seems to be the 
capital point in the treatment, for if the case does well it does well from 
the very first, from the moment of the primary cleansing. In fractures 
of the upper extremity with much shattering, the broken surfaces of the 
bone may advantageously be made regular by a formal excision, because 
mobility rather than solidity is sought for; while in the lower limb under 
similar circumstances as much of the bone should be preserved as is pos- 
sible, in order that the support may be solid even if the mobility is lost. 
Oilier 1 has pointed out clearly the change effected by the antiseptic 
method in the indications for resection after compound fractures of joints 
in consequence of their diminished gravity when treated conservatively 
under the Lister dressing. The surgeon can advantageously wait in 
doubtful cases, as Von Langenbeck 2 also showed by his analysis of the 
results obtained after gunshot w T ounds of joints, until the parts shall have 
shown the limit of their ability to repair their injuries unaided, and 
then, if necessary, amputation or secondary resection can be undertaken. 
The experience of both these surgeons has shown that the applicability 
of partial excisions is greater than has been supposed, of excisions, that 
is, in which only a portion of the articular surface is removed, whether 
it be the entire end of one of the members or contiguous portions of both. 
Instead of a formal excision, — that is, of an operation consisting in the 
removal of all free or fissured splinters and the regularization of the 
ends of the bone, — Oilier limits his interference to the removal of foreign 
bodies and completely detached splinters, leaving those that are still ad- 
herent to the periosteum, even if only partially so. The death of a 
splinter is due not so much to the traumatism as to the subsequent inflam- 
mation and suppuration. If these are avoided the splinter preserves 
its vitality as after simple fracture. The main condition of success is 

1 Resections et pansernents antiseptiques, in Revue Mensuelle de Med. and Cliir.. 
1880 pp. 926 and 931. 

2 Archiv fur Klinische Chirurgie, 1874, vol. xvi. 

13 



194 TREATMENT OF FRACTURES. 

that the cavity, and in this term are included all the pouches of the syno- 
vial sac, shall be efficiently drained, and therefore Oilier multiplies his 
counter-openings and drains, and diminishes the number of his sutures. 

Mr. Lister's practice, according to Cheyne, 1 is to enlarge the opening 
freely when it communicates directly with the joint, and to wash out the 
cavity with the 1 in 20 carbolic solution if the wound is seen within an 
hour or two of its receipt, or with the 1 in 5 alcoholic solution if a longer 
time has elapsed, using a gum catheter in order to reach all its recesses. 
If the communication with the joint is through a fissure in the bone, as 
in fracture of the lower third of the femur with splitting of the con- 
dyles, he makes a separate incision into the joint at a point suitable for 
drainage, washes it out, and inserts a drainage-tube at each opening. 

Gunshot fractures owe their special gravity to the shattering of the 
bone and the contusion of the soft parts, conditions which render suppu- 
ration inevitable, and increase the probability of the occurrence of severe 
osteomyelitis. The necessity for the rigorous employment of the anti- 
septic method is therefore all the greater, and experience has shown that 
its results are favorable. Some of these results have been already 
quoted in Chapter II., together with the choice of operation in the inju- 
ries of the different limbs. Sufficient experience, perhaps, has not yet 
been accumulated to show how far conservative treatment may be safely 
carried, but the facts collected from the Holstein, Austrian, and Franco- 
German wars, and so carefully analyzed by Yon Langenbeck, and the 
scattered reports of some army surgeons after the more recent wars, 
prove that in gunshot as in other compound fractures an attempt to pre- 
serve the limb may be made under antiseptic precautions, without increas- 
ing the risk to the patient's life, if prompt recourse is had to secondary 
amputation or excision when the indications for them appear. It seems 
not unlikety that when the bone is covered by thick layers of muscle, as 
in the thigh, Prof. Markoe's method of " through drainage" with fre- 
quent injections would be especially useful in the first week by promptly 
removing the gangrenous shreds cast off from the sides of the wound, and 
by assuring an asepticity which, perhaps, could not be obtained by a 
single irrigation at the first dressing. 

Immediate amputation after compound fracture is indicated when 
there exist in addition injuries to the main bloodvessels which make the 
preservation of the limb impossible, or to the nerves which would render 
it useless, or to the soft parts so extensive, or in such positions, that the 
cicatrix would create a disability greater than that of the loss of the 
limb, or when the bone is literally smashed over a great extent and the 
neighboring joints are involved. 

Secondary amputation finds its indications in profuse and prolonged 
suppuration that cannot be checked and that endangers the patient's life, 
or after a failure to keep the wound aseptic and the consequent destruc- 
tion of parts which it had been thought possible to save, or in similar 
conditions in articular fractures when excision is contra-indicated. 

There will always be cases in which the greatest uncertainty and 
anxious doubt will be felt by the surgeon, and this doubt is by no means 

i British Med. Journal, Nov. 29, 1879, p. 859. 



TREATMENT OF FRACTURES. 195 

greatest in those whose experience is the least extensive, since a single 
failure may leave a painful impression, or have a weight that many suc- 
cesses cannot remove, or entirely overcome. But, in consideration of its 
importance, I may repeat that we have in the antiseptic method a means 
of safely postponing the decision in these doubtful cases, of giving the 
patient the chance, and waiting until he has shown his ability or his 
inability to profit by it. 

If amputation is considered necessary immediately after the accident 
it should be performed without delay, for all are agreed that the dangers 
of the operation are increased by the necessity of cutting through the 
inflamed tissues of a feverish patient. Experience has also shown that, 
the period for immediate amputation having passed, it is better to wait 
until suppuration has become fairly established and the general reaction 
and acute inflammatory condition of the parts have subsided. But this 
is not to be taken as a fixed and inflexible rule, for many surgeons hold, 
and with apparent reason, that although the results of late, secondary, 
amputation are statistically better than those of amputation performed 
during the acute inflammatory period, yet many patients whose opera- 
tions are postponed succumb before the period considered fit for the ope- 
ration has been reached, and this mortality should be added to that of 
the secondary amputations in making the comparison. Instances are not 
lacking in which amputation, under conditions which made the preserva- 
tion of the patient's life in either case apparently hopeless, has resulted 
successfully. 

In conclusion, I may quote some of the sentences w T ith which a surgeon 1 
of large experience terminates his consideration of this subject. "This 
question," he says, " of the propriety of amputation is one of the most 
difficult which the surgeon has to solve, and it is impossible to state cate- 
gorically what cases need it, and what cases can recover without it. In 
doubtful cases I lean always towards preservation of the limb, and while 
recognizing that primary amputations are less dangerous than secondary 
ones, I prefer to take the chance of saving the limb. But when it be- 
comes clear that all hope of doing this is lost, I do not allow myself to 

be stopped by the gravity of the situation I believe one is 

justified in amputating so long as purulent infection (pyaemia) has not 
actually taken place. The cases quoted, and the number could be in- 
creased, prove this sufficiently. . . . Finally, we may be called upon to 
amputate to protect the patient from the consequences of suppuration 
and hectic fever. At what period should the decision be made ? Upon 
this point I can say nothing positive. Each case presents special indi- 
cations. The only recommendation I can offer is not to wait until the 
patient is completely exhausted by the suppuration." 

I append also a few of the late Prof. Cowling's " Aphorisms on Frac- 
tures " because they present the ideas in a compact and easily remem- 
bered form: — 

" With the improved methods of treatment the danger to life and limb 
in compound fracture has been reduced to such an extent that former 
laws for determining the question of amputation are to be recast." 

1 Valette, in the Diet, de Med. et Chir. Pratiques, article, Fracture, p. 502. 



196 TREATMENT OF FRACTURES. 

" The best time to dress any fracture is immediately after its occur- 
rence." 

" Temporary dressings are only to be used when the materials for 
permanent dressings are not to be obtained, or for the purpose of moving 
the patient." 

" The indications for treatment of fracture are, first, reduction of the 
fragments of bone, second, their immobilization." 

" Perfect immobilization is only to be obtained when the joints con- 
tiguous to the fracture are secured; and there is no law more important 
than this in fractures of the lower extremity." 

" One of the commonest reasons for the failure and disaster in the 
treatment of fracture arises from the fact that bone and muscle only are 
considered, and bloodvessels and nerves are left out of sight." 

" Carved and manufactured splints generally fit nobody, and are to be 
rejected as not only expensive but damaging. Deal board, pasteboard, 
and the materials for the plastic apparatus form all the appliances needed 
by the surgeon." 

" The application of a bandage immediately to the skin, whether as a 
protection or to prevent muscular spasm, has resulted in such disaster, 
that it is one of the curiosities of surgery how it could be repeated at 
this day. When cotton is placed over such a bandage it forms an ab- 
surdity scarcely credible in a man of ordinary sense." 

" Comfort is the sign that a fracture has been properly dressed. . . 
The general law is that pain should speedily subside when the dressings 
are not at fault." 

" Frequent dressings of fractures for the purpose of examination are 
not only useless but hurtful." 

" Whenever it is possible, after the dressing of a fracture, it should 
be seen again in a few hours, and the case should receive daily attention 
in its earlier stages." 

" The surgeon is to regard not only the welfare of his patient, but his 
own reputation. To this end he ought to give fair warning of possible 
ill results. . . . There is one thing which the law is slow to excuse 
—neglect." 



PSEUDARTHROSIS AND DELAYED UNION. 197 



CHAPTER IX. 

PSEUDARTHROSIS AND DELAYED UNION. 

In a relatively small number of fractures of the shaft of long bones 
it is found on examination of the limb at the expiration of the period 
which is usually sufficient for the completion of repair that the frag- 
ments are still movable upon each other. The degree of this mobility 
and the length of time during which it persists are variable. When it 
is slight and but a few weeks or months have elapsed since the injury 
was received, it is usually spoken of as delayed union ; when more free 
and painless, and when several months have passed the condition is de- 
scribed as a pseudarthrosis. The distinction has an important practical 
value, for it has much weight in determining the choice of a method of 
treatment; union that is simply delayed will often become complete, that 
is, the existing soft callus will complete its natural evolution by ossify- 
ing, by the aid merely of a dressing that immobilizes the parts, while a 
pseudarthrosis can be overcome only by operative measures of greater 
or less severity. 

Delayed union that does not terminate in pseudarthrosis causes but 
little inconvenience beyond the prolongation of the treatment, but pseu- 
darthrosis may result in a disability so complete that amputation of the 
limb is sought as an amelioration. This is rare, and is found only in 
the lower extremity ; pseudarthrosis of either the arm or forearm can be 
sufficiently controlled by mechanical appliances to enable the patient to 
make good use of the limb, and even in some cases the abnormal mobility 
is so slight that no additional support is needed. 

Fibrous union of a fractured short spongy bone or the expanded ex- 
tremity of a long one, or between an apophysis and the bone from which 
it has been torn is not usually spoken of as pseudarthrosis, and, as has 
been elsewhere shown, is a common result after fracture of the patella 
and of apophyses to which powerful muscles are attached. 

Norris, 1 who wrote the first elaborate article upon this subject, one 
that has served largely as the basis of most subsequent ones, described 
four varieties of incomplete union, which, however, if differences in 
degree are disregarded, may be reduced to two : 1st, those in which a 
more or less extensive fibrous band, with or without nodules of bone de- 
veloped in it or on the surface of the fragments, unites the latter ; 2d, 
those in which an actual joint with a capsule and cartilaginous surfaces 
is formed by the broken ends. The second form is rare ; the first is the 
common one and presents several important differences in degree. 
Thus, the ends of the bone may be in good position and enveloped in a 

1 Am. Journal Med. Sciences, 1842, vol. xxix. p. 13. 



198 PSEUDARTHROSIS AND DELAYED UNION. 

large callus which lacks only ossification to make the union perfect. It 
is an arrest of the normal process of repair at a comparatively late 
period, may be recognized by the presence of the callus and the pain 
caused in it by communicated movements, and is amenable to treatment 
by simple methods which favor or excite ossification. Or the union may 
consist of a longer or shorter, more or less voluminous bundle of fibrous 
tissue uniting the bones end to end when they have been kept in position, 
or laterally when they have over-ridden. The ends of the bones are altered 
by a formative or rarefying osteitis which produces in the one case 
closure of the medullary canal by a bony deposit, and nodules upon the 
surface, in the other the absorption of prominent points and angles, and 
the reduction of the ends to conical points. In a remarkable and ex- 
ceptional case quoted by Norris from the Boston Medical and Surgical 
Journal, July 11th, 1838, p. 368, a lad, 18 years old, broke his right 
humerus near its middle ; while repair was apparently progressing favor- 
ably he fell and again broke the arm at the same place. This time the 
fragments not only failed to unite but disappeared gradually by absorp- 
tion until all the bone between the shoulder and the elbow had disap- 
peared. When last seen, eighteen years later, the arm hung loose from 
the shoulder and could be twisted twice completely around without pain. 
On traction it would extend to a length equal to that of the other, and 
then if released would immediately shorten about six inches. 1 Agnew 2 
refers to a case under his own observation in which half the humerus 
had disappeared in eight years after fracture. Gurlt quotes a some- 
what similar case reported by Peacock. 3 A lad, 18 years old, had a 
pseudarthrosis of the femur that had lasted ten months and was then 
treated unsuccessfully by resection. Three months later the limb was 
amputated on account of prolonged suppuration and hectic fever. It 
showed serous infiltration of the connective tissue, marked atrophy of 
the muscles and especially of the bone which consisted of little more 
than a shell one-tenth of an inch thick at the thickest part. The lower 
fragment was even thinner, and where the two fragments were in contact 
the spongy tissue had been entirely absorbed. The atrophy involved 
the entire lower end of the bone, which could be easily cut with a knife. 
The tibia, fibula, and bones of the foot were softened, and their compact 
tissue had been in part replaced by marrow. 

The mobility in these cases of fibrous union depends upon the length, 
number, and position of the connecting bands. When the fragments 
override for a considerable distance, as in a fine specimen of ununited 
fracture of the upper third of the femur, which is preserved in the Belle- 
vue Hospital Museum and was taken from a patient at one time under my 
care, and are supported by contact with, and fibrous attachments to, 
bony prominences the mobility will be very slight and the limb, perhaps, 
useful ; when, on the other hand, they are end to end and the union 
consists only of slight fibrous bands, or even of merely a fibrous thick- 
ening of the adjoining muscular layers, the mobility may be very free. 

1 The man died at the age of 70, and the report of the autopsy is given in the 
Boston Med. and Surg. Journal, October 10th, 1872. 

2 Surgery, vol. i. p. 746. 

3 London Med. Gazette, 1838-39, vol. ii. p. 847. 



PSEUDOARTHROSIS AND DELAYED UNION. 199 

In the other form an actual joint is formed, the ends of the bones are 
more or less enlarged by new deposits, rounded and smooth, and covered 
entirely or in part by cartilage. They are united by a complete periph- 
eral capsule and moistened by a liquid resembling synovia. The por- 
tions of the contiguous surfaces not covered by cartilage are eburnated 
and made smooth by friction upon each other. Although I have met 
with no recorded case in which it is distinctly stated that the cartilagi- 
nous character of the tissue covering the ends of the bones was deter- 
mined by microscopical examination, and although it is known that 
wounded cartilage repairs itself usually by fibrous tissue, yet I believe the 
tissue to be real cartilage, in some cases at least, because it has been de- 
monstrated to be so in one case 1 of false joint established intentionally by 
operation, and because, as we have seen, the callus is cartilaginous during 
one period of its development. It seems justifiable to assume that por- 
tions of this cartilaginous callus may persist and remain as articular car- 
tilage just as portions remain in the normal embryonal formation of 
bones and joints. An additional point of resemblance to normal joints 
is found in the loose cartilages which are occasionally found within 
these joints of new formation. A specimen of this kind is pictured in 
the first volume of Holmes's System of Surgery. Grurlt 2 collected five 
cases of this form of pseudarthrosis in the arm, three in the forearm, 
and two in the thigh, verified by post-mortem examination. 

Pseudarthrosis is not easily produced intentionally in animals, but 
Breschet succeeded in obtaining six specimens which showed distinct 
cavities with capsular ligaments and synovial liquid. The synovia appeared 
at the latest on the twenty-seventh day, and the older the fracture the more 
had the walls of the cavity lost their pink color, and become smooth and 
polished on the inside, and showed externally the appearance of fibro- 
cartilage. The eansule surrounded the broken ends and was continuous 
with them. In some cases he found the broken surface of an opaque, 
white color, glistening like synovial membrane, and covered by tissue 
resembling articular cartilage. A period of eighty-five days was suffi- 
cient for the production of this condition in a dog. 

The different statistics and estimates that have been published con- 
cerning the frequency of failure of union as compared with the total 
number of fractures vary within wide limits, but all agree in making it 
small. The following are taken from Norris, Gurlt, and Agnew : Pier- 
son found only 1 case in 367 fractures treated in the Massachusetts Gen- 
eral Hospital ; Lonsdale only 5 or 6 in 4000 fractures treated in the 
Middlesex Hospital in London ; Stanley remembered none in sixteen 
years at St. Bartholomew's Hospital in London, and Mr. Callender 3 says 
that in the seven years ending in 1867 there had been treated in the 
same hospital 2376 fractures, exclusive of those of the upper extremi- 
ties, and " with the exception of certain fractures of the patella and 
neck of the thigh bone there had been but one case of non-union." 
There was none in 916 cases of fracture treated in the Pennsylvania 

1 Sayre's Orthopedic Surgery, 1876, p. 442. 

2 Loc. cit., p. 592. 

3 Med. Chir. Trans., vol. li. p. 148. 



200 



PSEUDARTHROSIS AND DELAYED UNION. 



Hospital between 1830 and 1839, and Agnew says he could learn of 
none among the 6480 fractures treated in the same hospital between 
1850 and 1874. Amesbury alone speaks of it as " by no means un- 
common," and places his personal experience at 56 cases. The conclu- 
sion to be drawn is that it is exceptionally rare under proper treatment, 
and that when it occurs under such circumstances it is generally due to 
a definite, recognizable cause independent of the treatment. 

The cases contained in the tables of Norris, Gurlt, and Agnew are 
divided as follows among the different bones : — 



Femur .... 
Leg (one or both bones) . 
Humerus . 
Forearm (one or both bones) 



Norris (1842). 


Gurlt (1S61). 


48 
33 
48 
19 


33perct. 
22 " 
32 " 
12 ^ 


132 
131 
165 

50 


27perct. 
27 " 
34 " 
10 "' 


143 




478 


. 



Agnew (1S7S). 

155 24perct. 

180 '28 " 

219 J34 " 

76 12 " 



630 



I presume that all of Norris's cases are included in both the other 
lists, and probably most, if not all, of Gurlt's are included in Agnew's, 
therefore the three lists cannot be added together to make a grand total. 
Furthermore, these figures do not represent an equal number of cases, 
for many of the cases appear several times in each list under the different 
methods of treatment. It will be noticed that the percentages of Gurlt's 
and Agnew's correspond yery closely, and that in them the pseudarthro- 
ses of the humerus are the most numerous, and those of the forearm the 
fewest. By reference to the general statistics given in Chapter I. it 
may be seen that fractures of the humerus are relatively few when com- 
pared with those of the other large bones of the extremities, and conse- 
quently the percentage of the cases in which union fails after fracture 
of the humerus is much greater, even in comparison to others, than the 
above lists indicate when taken alone. Agnew's list contains 3T cases 
of non-union of both bones of the forearm, 23 of the radius alone, and 
16 of the ulna alone ; 94 of both bones of the leg, 84 of the tibia 
alone, and only 2 of the fibula. 

Gurlt's analysis shows the same preponderance of pseudarthrosis as 
of fracture in males, and the greatest frequency of both between the 
ages of 20 and 30 years ; but, on the other hand, an important difference 
in childhood. While his general statistics show that fractures are almost 
as frequent in the first ten years of life as they are in the third decade, 
during which they are more frequent than in any other, the proportion 
of pseudarthrosis in the same periods is only as 1 to 8. This rarity of 
non-union in childhood is doubtless due to the vigor of the healing pro- 
cess at that age. His statistics show further, in contradiction of a rather 
widely held opinion, that advanced age is not unfavorable to repair, and 
that, all things considered, non-union is more common in the prime of 
life than at any other period. Norris claimed, on the strength of re- 
corded observations and daily experience, that advanced age was not to 
be considered among the causes of non-union, and quotes some cases in 
which union took place within the usual time in very old patients. 



PSEUDARTHROSIS AND DELAYED UNION. 201 

The causes of delay or failure of union are general and local, those 
which lie in a constitutional vice or temporary deterioration of the con- 
dition of the patient, and those which lie in the fracture itself or the 
associated injuries. These causes may act simultaneously or separately, 
and, as may be inferred from what has been said concerning the rarity 
of this result, are by no means certain to produce it in any given case 
in which they may be operative. The repair of a fracture requires a 
special productive effort on the part of the injured tissues, and, as is seen 
occasionally after injury of other parts, the resources of the organism 
are sometimes insufficient to meet the demands made upon them ; the 
local causes are usually mechanical. 

The general causes to which the occurrence of pseudarthrosis has been 
attributed in different cases are tabulated by Gurlt, who follows Xorris 
in this quite closely, as follows : — 

1. Syphilis. 

2. Pregnancy. 

3. Physical deterioration. 

a. Due to a drain upon the system (hemorrhages, lactation). 

b. Due to general debility (especially from insufficient nourish- 

ment). 

4. Advanced age. 

5. Severe acute diseases (typhoid fever, variola, etc.). 

Of each of these except the fourth he quotes a few instances, but 
couples them with others to show that the influence is a slight one. 
Of the fourth he quotes only cases to show that prompt union is possible 
in very old people, and refers to the statistics already given to prove 
that the frequency of non-union is not disproportionately large in old age. 

Of the local causes the same may be said as has just been said con- 
cerning the general ones ; any one may prevent or delay union, but 
none will certainly do so. Some act mechanically, some by change in 
the blood or nerve-supply of the parts, others by modifying the produc- 
tive process either directly by disease in the broken ends of the bones, 
or indirectly by inflammation of the surface of the limb. They may be 
divided as follows for detailed consideration : — 

1. Unfavorable relations or conditions of the fractured parts. 

2. Interposition of a foreign body. 

3. Defective innervation. 

4. Defective blood-supply. 

5. Disease of the bone. 

6. Inflammation on the surface. 

7. Defective treatment. 

1. The unfavorable relations or conditions of the fractured parts con- 
sist in separation of the broken surfaces by over-riding or extreme lateral 
displacement of the fragments, and loss of substance by splintering, re- 
section, or necrosis. Lack of contact between the broken surfaces is 
the most frequent cause of non-union, and it is observed not only when 
the ends of the fragments are separated longitudinally, but also when 
the line of fracture is oblique and one of the fragments has the constant 
tendency to lateral displacement which has been mentioned elsewhere 
as common in some fractures of the tibia. Not only does the actual 



202 PSEUDARTHROSIS AND DELAYED UNION. 

separation act unfavorably, but the mobility, which alone allows the 
separation to take place after reduction has been made, adds another 
obstacle to union. Loss of substance due to partial necrosis of one or 
both fragments is less likely to cause non-union than loss of substance 
due to comminution or resection, because in, the former case the perios- 
teum of the necrosed portion is more likely to preserve its position and 
to be stimulated to produce rapidly a shell of new bone to take the place 
of the sequestrum as soon as the latter is removed. 

2. Foreign bodies introduced from without, such as bullets or portions 
of the tissues of the limb, splinters, muscles, or tendons, and possibly 
even blood-clots may delay or prevent union by occupying the space which 
would otherwise be filled by the callus. Splinters of bone, as we have 
seen, usually preserve their vitality, or, even if dead, may become firmly 
imbedded in the callus, and serve to strengthen the union in simple frac- 
tures. In compound fractures which suppurate they may die and then 
act like a foreign body introduced from without. Portions of muscle are 
liable to become interposed only in fractures accompanied by considerable 
displacement and laceration of the soft parts, and when, the fracture 
being very oblique, the sharp end of one fragment has been driven into 
the muscle and has not been withdrawn. Gurlt thinks this complication 
is probably comparatively common, and is the cause of many of the 
slight delays noticed in consolidation. The examination of various spe- 
cimens has shown that muscular bundles thus interposed atrophy by dis- 
use or pressure, and may disappear entirely. Collections of blood are 
thought by some to act in a similar manner, but the study of the normal 
process of repair and clinical observation of some cases of fracture com- 
plicated by traumatic aneurism indicate that the obstacle thus created 
must, if it exists at all, be very slight. Granulations penetrate a soft 
clot very readily, and hasten its absorption, and it is even claimed in 
some quarters, although improperly in my opinion, that the clot is capa- 
ble of producing new tissue within itself, and without extraneous aid. 
The observations which have led to this belief show at least that the 
clot is not an obstacle to repair, either of soft parts or of bone. 

3. Defective innervation. It has been repeatedly asserted and de- 
nied, and both opinions supported by the citation of cases, that injury 
to the nerves supplying a fractured limb or to the spinal cord above the 
origin of such nerves impedes or entirely prevents the formation of a 
callus. The disagreement appears to have arisen through a failure to 
discriminate between the paralyses in the different cases, and the same 
error has affected many of the experiments made to elucidate the ques- 
tion. A recent thesis by Bognaud, 1 presents the facts very clearly, and 
shows by clinical and experimental observations that certain portions of 
the nervous system do exercise a trophic influence upon the bones as 
upon other tissues, and that the destruction of the nerves through which 
this influence is conveyed, or of the centres at which it arises, prevents or 
retards consolidation. The most frequent examples are furnished by 
fractures of the lower extremity with concomitant injury to the spinal 

5 Sur 1' Influence de quelques lesions du systeme nerveux sur la formation da cal. 
These de Paris, 1878, No. 370. 



PSEUDARTHROSIS AND DELAYED UNION. 203 

cord. In paralysis due to a lesion limited to the upper portion of the 
cord, the lower segment remaining intact, repair is not interfered with, 
but on the contrary, is rather aided by the immobility and insensibility 
produced by the paralysis. The explanation is found in the supposed 
existence of trophic centres in the lower portion of the cord, from which 
trophic nerves pass in company with the others to be distributed to the 
lower limb. 

Bognaud collected six cases of fracture of the leg, or of the fibula alone, 
with complete paraplegia due to simultaneous fracture of the vertebral 
column at or below the last dorsal vertebra, in which consolidation failed 
entirely to take place ; and he gives others in which, the paralysis being 
incomplete, or the lesion of the spine situated at a higher point, partial 
or complete repair followed. He reports also in full a case which came 
under his own observation of fracture of the humerus in a healthy man 
of 24 years, due to a fall which occasioned also paralysis of all the 
muscles of the same arm, except the deltoid, and almost complete loss of 
sensibility in the limb. Three and a half months afterwards, when the 
record ends, there Avas not the slightest trace of union of the broken 
bone. The fracture had been judiciously treated in hospital, and during 
the last month and a half electricity, first by the interrupted and then 
by the continuous current, had been employed in vain by Broca. 

4. Defective blood supply, the result either of occlusion of the prin- 
cipal artery of the limb, or, more especially, of the relations of the nu- 
trient artery of the bone to the fracture, has been considered a cause of 
non-union. The only case mentioned by the authors, in which repair 
seems to have been retarded by occlusion of the main artery of the 
limb is one reported by Dupuytren, 1 a fracture of the leg in a woman 
aged 62, whose femoral artery he had tied on aceount of a traumatic 
aneurism caused by the fracture. Consolidation had scarcely begun at 
the end of the first month, and was not complete until after the expira- 
tion of four months. On the other hand, there are a number of cases 
recorded in which a similar operation caused no delay, and from our 
knowledge of the rapidity with which the collateral circulation is estab- 
lished, there seems no reason to suppose that the ligature of the main 
artery can have any material influence upon the consolidation. 

A similar conclusion must be reached reo;ardin£ the influence of the 
nutrient artery. Gueretin, and subsequently Norris, collected some 
statistics designed to show the position of the ununited fracture with 
reference to the point of entrance and the direction of the nutrient artery. 
The results were conflicting. Gueretin collected 35 cases of ununited 
fracture, in only 10 of which the injury was situated in the portion of 
the bone towards which the artery was directed ; Xorris collected 41 
cases, in 27 of which the injury occupied that portion. Taken together 
the two lists give 76 cases with 37 fractures on one side of the point of 
entrance of the artery, and 39 on the other. 

The statistics themselves are untrustworthy, as Norris admits, because 
the observations were not controlled by dissection, and the point at which 
the artery enters the bone varies widely. Curling thought he found 

1 Quoted by Malgaigne, loc. cit., vol. i. p. 144. 



204 PSEUDARTHROSIS AND DELAYED UNION. 

corroborative evidence of the correctness of the claim in an alleged par- 
tial atrophy, after fracture, of the fragment towards which the artery was 
not directed, but Gurlt, who afterwards examined his specimens, declared 
himself unable to recognize any difference between the two parts. As 
the soft parts, and especially the periosteum^ take a much more promi- 
nent part in the formation of the callus than the bone itself does, and as 
their blood-supply is not received through the nutrient artery, and as 
we have learned that even total separation of a splinter does not neces- 
sarily cause its death, the theoretical support of the assertion is no 
stronger than that supplied by observation, and it must be dismissed as 
entirely unproven and improbable. Indeed, an argument based upon a 
supposed inequality in the blood-supply due to the direction of the nu- 
trient artery would justify equally well a conclusion directly opposed to 
the one reached by these writers, for, if the amount of the blood supplied 
to a bone through its marrow varied in the different parts according to 
the direction of the nutrient artery the half which received the less 
amount in this manner would, theoretically, have to receive a relatively 
larger amount through the vessels of the periosteum in order to make good 
the difference, and, thus receiving a larger amount from its surface, and 
less through its central canal, would be less affected by a fracture which 
cut off the latter supply. 

5. Disease of the bone. Any of the diseases which have been men- 
tioned as possible factors in the etiology of the so-called spontaneous 
fractures, syphilis, cancer, hydatid or other cysts, may interfere in like 
manner to delay or prevent consolidation. Gurlt' s table contains four 
such cases, two of hydatids and two of syphilitic exostoses. The com- 
monest cause of this kind, however, is suppuration of the bone maintained 
by a splinter or a necrosed fragment. The influence exerted by the 
presence of such a body may delay consolidation until its removal, or 
may lead to the absorption of a callus already formed and perhaps even 
sufficient to unite the fragments firmly. The removal of the splinter or 
of the sequestrum is usually followed by complete recovery, but in some 
cases permanent pseudarthrosis has resulted. Gurlt quotes the following 
interesting case from Gerdy. 1 In a man whose right arm had been 
broken by a gunshot nine years before and had slowly united, an abscess 
formed at the site of the fracture, was opened, and gave exit to several 
small fragments of bone. It failed to close, the callus softened, and 
notwithstanding proper treatment the bones failed to reunite ; the patient 
became hectic, and the limb was amputated. The bone was found dis- 
tinctly inflamed, spongy, and traversed by vessels. The marrow was 
slate-colored in places, red in others, and suppurating at the points cor- 
responding to the wound. 

6. Inflammation on the surface of the limb. Malgaigne 2 says that 
phlegmons and erysipelas occurring in a fractured limb generally retard 
the solidification of the callus, and he quotes a case that came under his 
own observation of a man who had broken one of his fingers ; a phleg- 

1 Chirnrgie pratique, 3me Monographic, Maladies des organes du Mouvement, Paris, 
1855, 8, p. 126. 

2 Loo. cit., p. 144. 



PSEUDARTHROSIS AND DELAYED UNION. 205 

monous inflammation was set up in the neighborhood of the fracture, the 
callus did not begin to form until after this had subsided, and consolida- 
tion was not complete until after two and a half months had elapsed. 

7. Defective treatment. This includes errors of commission and omis- 
sion. Among the former is reckoned the prolonged use of cold applica- 
tions, and there is every reason to believe that when cold is used in its 
most active and efficient forms, such as bags of cracked ice or irrigation 
through a coil of lead tubing, upon limbs that are not acutely inflamed 
the consolidation of a fracture may be considerably delayed thereby. 
Malgaigne goes much further and accepts the theory, which he traces 
back to the times of Paulus Aegineta and Avicenna, that moist applica- 
tions, hot as w T ell as cold, are injurious. The same charge has been 
made against the method of continuous irrigation of a wound, and in the 
statistics of nine compound fractures treated in this manner collected by 
Nivet 1 it appears that only two consolidated within the usual time, four 
required from two and a half to seven months, one was dismissed un- 
cured after more than six months of treatment, and two died. Gurlt 
urges, very properly as it seems to me, that there are so many other 
factors involved in these cases that it is difficult to draw any positive 
conclusions concerning the influence of the treatment in causing the delay 
of the consolidation. 

Soon after the introduction of the immovable dressing in the treat- 
ment of fractures, the charge was made that it favored non-union or 
delay of union, especially if applied immediately after the accident. 
Malgaigne pointed out that the cause in the cases cited was not the 
early application of the dressing but possibly its too tight application, 
and the correctness of this explanation has been amply demonstrated 
clinically and experimentally. Malgaigne was at a loss to reconcile 
some of the facts with the theory of too great compression and sought 
an additional cause in the prolonged withdrawal of the limb from the 
light and air, a circumstance to which attention had first been called by 
Cloquet as the cause of the changes occasionally observed in those times 
and known as local scurvy. The picture drawn by Cloquet, 2 and quoted 
by Malgaigne as too exact to be improved, of this condition of the limb 
corresponds to nothing that has come under my observation or that is 
described by modern writers, and I am disposed to believe, therefore, 
that while the prolonged retention of fixed dressings may favor its pro- 
duction, yet the actual cause is to be sought elsewhere, probably in the 
wretched hygienic surroundings of the hospital patients of those times, 

1 Gazette Medicale de Paris, 1838, p. 36. 

2 He says : " The limb seems to lose its temperature ; the skin takes on a dull white 
or leaden color, swells, and softens. The epidermis is raised and detached ; sometimes 
blebs are formed with puriform or slightly viscid contents ; the skin below them 
seems mucous and swollen ; the hair falls. If the fracture is complicated by a wound 
the granulations swell, become flabby and livid, furnish only an ichorous pus, and 
bleed at the least touch. Soon ecchymoses appear, usually about the bulbs of the 
remaining hairs, increase in size, and spread over the entire limb. The work of re- 
pair is arrested, mobility persists at the fracture at a period when consolidation should 
be complete. Sometimes hemorrhages take place at different points upon the softened 
skin. In many cases the general condition of the patient seems entirely foreign to 
these local changes ; the gums are firm, do not bleed, and are not swollen. The ap- 
petite, digestion, sleep, and moral are unchanged." 



206 PSEUDARTHROSIS AND DELAYED UNION. 

and in the moral and physical degradation of the class from which those 
patients were drawn. 1 

Mobility of the fragments, due either to the indocility of the patient, 
the inefficiency of the retentive apparatus, or the absence of treatment, 
is a common and universally admitted cause of failure or delay of union. 
Amesbury attributed to it an insufficient reduction of all but six of the 
fifty-six cases that came under his observation ; Norris says that of the 
forty-four cases in his own table in which the probable cause of the 
pseudarthrosis is mentioned twenty-two may be fairly attributed to undue 
mobility, but he adds that the information furnished in the records of 
the cases cannot be entirely depended upon. Gurlt gives the details of 
a case in which the repair of three successive fractures, thigh, leg, and 
arm, was long delayed by recurring epileptic attacks, and of another in 
which paralysis agitans produced the same result after fracture of the 
humerus. 

The premature use of a broken limb may not only result in secondary 
fracture, as has been mentioned in the preceding chapter, but may also 
arrest consolidation or even provoke absorption of the callus and result 

1 Of these surroundings and this degradation it cannot he easy to form an adequate 
conception. During one of the "glorious" periods of the history of France, say 
from 100 to 200 years ago, the descriptions of the conditions of the people furnished 
hy eye-witnesses are almost incredible. The superior of a convent at Blois, in the 
richest part of the most fertile province, says "the poor are without bread, without 
clothes, without linen, without furniture, in short, deprived of everything ; they are 
black as Moors, most of them skeletons and the children all swollen. Women and 
children are found dead in the roads and in the fields, their mouths filled with grass." 
A correspondent of Colbert writes to him " the inhabitants of this province have lived 
through the winter on bread made of acorns and roots, and now they eat the grass of 
the fields and the bark of the trees." A few years later La Bruyere writes " we see 
certain wild animals, male and female, scattered through the country, black, livid, 
burnt by the sun, attached to the soil which they cultivate with an invincible deter- 
mination ; they have a sort of articulate voice, and when they rise upon their feet 
they show a human face, and, in fact, they are men. They retire at night into dens 
where they live upon black bread, water, and roots." In 1698 a tax gatherer reports 
that in the district of Rouen which had always been one of the most industrious and 
well-to-do provinces " out of 700,000 inhabitants there are not 50,000 who eat their 
bread at their ease and sleep upon anything but straw." Similar accounts were re- 
ceived from all quarters, ''the peasants about Moulins are black, livid, and almost 
hideous ; they live on chestnuts and radishes like the beasts." Vauban writes " the 
tenth part of the people are reduced to actual beggary ; of the other nine-tenths five 
can give no alms because they are themselves almost reduced to the same need ; of 
the remaining four, three are very badly off." Massillon says, "our people are 
living in frightful misery, without beds or furniture, the only food of most of them 
during half the year is barley or oatmeal." These reports, and others like them, 
cover not a single short period, but the entire century, and the condition lasted up to 
the Revolution. From such people and from the corresponding class in the cities came 
the hospital patients. 

And how were they cared for in the hospitals ? The Hotel Dieu in Paris contained 
in 1709 more than 9000 patients, packed together four, five, nine, and even twelve in 
a single bed. r ihe beds were ranged over each other like berths in a ship, and the 
dead, dying, and living were all mingled together. The convalescent ward could be 
reached only through the smallpox ward ; the ward for surgical cases adjoined that 
occupied by the lunatics, " whose frenzied cries could be heard day and night." Not 
until 1790, less than one hundred years ago, were these conditions changed, and the 
change consisted in the removal from the hospital of a tallow chandlery and a slaughter 
house which with grim kinship had hitherto formed part of it, and in the reduc- 
tion of the number of patients to 1800, and subsequently to 800. What value can be 
placed upon statistics of results obtained upon such patients and under such con- 
ditions ? 



PSEUDARTHROSIS AND DELAYED UNION. 207 

in pseudarthrosis. This is most liable to occur in very oblique fractures 
and in those marked by much over- riding. It is not very uncommon to 
see a fractured limb bend under the weight of the body and present a 
notable deformity if the patient has been too eager to use it and prove 
his complete recovery. Callender 1 asserts very positively that move- 
ments communicated to a limb during the repair of fracture with a view 
to prevent anchylosis of neighboring joints are a frequent cause of non- 
union, especially movements of the elbow after fracture of the humerus, 
and he advises that all attempts to overcome stiffness in any joint should 
be postponed until the bone is firmly united. 

Softening and absorption of a callus that has already formed and 
become firm have been observed in a number of cases, even after re- 
covery has appeared complete and the patient has used the limb for 
some time, but more commonly at a period less remote from the accident. 
The causes usually lie in some of those diseases or complications which 
have been spoken of as occasionally delaying repair, such as erysipelas, 
phlegmonous inflammation, variola, continued fevers, scurvy, and in 
some few cases it has occurred without recognizable cause. Fanon 2 
reports a case in which the callus softened twice after fracture of the 
leg. Eighty days after the injury the limb appeared solid and the 
patient began to use it. Two days afterwards the mobility was as great 
as ever. The patient was sent to the country, and in six weeks the limb 
was again solid. After using it for a few days again the mobility re- 
turned, and then, it having been discovered that the patient had been 
rachitic in youth, she was treated with the acid posphate of lime. Seven 
months after the accident the fracture was permanently united. I re- 
produce from Malgaigne and Gurlt the following cases illustrative of the 
other causes. 

A man, forty-five years old, received a fracture of the leg which was 
consolidated by the fiftieth day. A month later erysipelas appeared on 
the leg, lasting two days; the callus disappeared and was not repro- 
duced until two months afterwards. 

In a case observed by Schelling a fracture of the femur had united so 
well that the patient could bear a certain weight upon the limb. He 
developed typhoid fever, and on the tenth day the callus had disap- 
peared. After his death, six days later, the ends of the fragments 
were found bleeding as after a recent fracture and enveloped in a sort of 
membranous sac, which contained a small amount of black liquid blood. 

A sailor broke his clavicle and was so far cured at the end of a month 
as to be able to use his arm as well as before the accident. Three 
months later, while he was hanging by the arm, the clavicle separated, 
and at the same time the symptoms of scurvy appeared. Consolidation 
did not again take place until after the cure of the scurvy at the end of 
six months. Under the same influence Marrigues saw the callus of a 
fracture that had been healed six months soften and disappear. A 
second consolidation followed the cure of the scurvy. 

Holscher cured a pseudarthrosis of the radius by resection. A year 

1 Med. Chir. Trans., vol. 51, p. 161. 

2 L'Union Medicale, 1859, vol. ii. p. 24. 



208 PSEUDARTHROSIS AND DELAYED UNION. 

and a half afterwards the patient became greatly reduced by diarrhoea 
and hectic fever, and the bones, which had been soundly united, again 
separated. 

Guersant treated a fracture of the femur in a boy ten years old ; by 
the twentieth "day firm union was obtained without shortening. The 
child was taken shortly afterwards with smallpox, the callus became pain- 
ful, and he died on the seventh day. The autopsy showed overriding to 
the extent of 1 J inches ; the callus was a soft ecchymotic mass, and the 
fragments were united by strings of a fibrous appearance. At no point 
in the callus was there the least sign of calcification. 

Kirkbride saw a man, twenty-one years old, who, a month after he 
had been discharged from the hospital cured of a compound fracture of 
the leg, returned with an ulcer over the seat of the fracture ; about 
three weeks later the ulcer became gangrenous, and before this was over- 
come the callus had been absorbed. By the application of caustic pot- 
ash to the ulcer and the bare ends of the bones the former was healed, 
and the latter reunited in six weeks. 

Finally, there is the case mentioned at the beginning of this chapter, 
in which a second fall caused a second fracture before the first was 
entirely healed, and led to the absorption, not only of the callus, but 
also of the entire shaft of the humerus. 

Gurlt maintains, in opposition to Malgaigne and Amesbury, that there 
exist a few cases in which non-union has resulted without recognizable 
cause in strong and healthy patients, and notwithstanding favorable con- 
ditions and appropriate treatment of the fracture. He cites in support 
of this opinion those cases of multiple fractures in the same patient, or 
the same limb, of which some unite and others remain ununited, and 
those of fracture of the forearm, in which only one bone unites. 

The diagnosis of non-union is made by the persistence of mobility 
beyond the period usually sufficient for consolidation, but the recognition 
of the exact condition of the parts is often difficult. This is to be ob- 
tained by palpation of the part, by recognition of the surrounding soft 
callus if one exists, or of the atrophied and separated ends of the bones, 
of the degree of mobility, by examination with acupuncture needles to 
determine the direction of the fracture and the relations of the fragments 
to each other, and by study of the subjective symptoms, the pain which 
accompanies even slight movements in delayed union, and the freedom 
from pain, even with extended movements, in true, well-established pseu- 
darthrosis. Crepitation, which exists only in the latter case, is not com- 
mon, and has the characteristics of that w T hich is found in joints altered 
by disease rather than of that found after recent fracture. 

The distinction between non-union and simple delay, so important in 
determining the method of treatment, cannot always be made by the 
objective symptoms ; the freedom of motion, the amount of pain, and 
the length of time that has elapsed must be taken into account. This 
distinction has an important therapeutic influence, because delayed 
union can usually be corrected by measures that do not involve any 
risk to the patient's life, such as fixation of the limb, reduction of dis- 
placement, change of surroundings, better nourishment, and stimulation 
of the fracture ; while, on the other hand, true pseudarthrosis requires 



PSEUDARTHROSIS AND DELAYED UNION. 209 

operative interference. While no definite period can be named after 
which pseudarthrosis alone can be said to exist, yet it may be stated, as 
a general rule, that the longer the time that has elapsed since the injury 
was received, the greater is the probability that a cure can be effected 
only by operation. 

The following case quoted by Gurlt from Casper's Wochenschrift, 
1846, p. 39, shows, -however, that a cure is possible without operation, 
even after a very long period ; an oblique fracture of the leg in a man 
more than forty years old, which had remained ununited for a year 
and a half, consolidated perfectly during a rest in bed for six weeks, 
rendered necessary by an intercurrent disease. 

Many cases are recorded in which the existence of a false joint did 
not interfere materially with the usefulness of a limb, the patients in 
some cases wore braces or supports, which gave the necessary stability 
even when the fracture was of the leg; or thigh, but in others the use- 
lessness of the limb ivas so complete, and the motions communicated to 
it by the ordinary movements of the body so painful, that amputation 
has been urgently desired and occasionally performed. During the pre- 
sent century many operative measures have been introduced for the relief 
of this disability, and all have had a certain degree of success, so that 
amputation on account of pseudarthrosis is now rarely required. The 
most unfavorable cases for a cure by operation are those in which the 
ends of the bone are markedly atrophied. 

Treatment. — Although the risks of active operative interference have 
been much reduced of late years, yet the rule of practice laid down 
many years ago in these cases still holds good ; the milder measures 
must be first employed, and an operation should be undertaken only after 
these have proved unsuccessful. Simple delayed union that has existed 
for only a few weeks without any marked displacement of the fragments 
or other recognizable local cause can usually be cured by the use of the 
immovable dressing persevered in for three or four weeks ; and in all, 
except perhaps the older cases, this measure should be tried and perse- 
vered in for many months, if partial gradual improvement can be recog- 
nized. With this must be combined the removal of any local or gen- 
eral cause, such as the overriding of the fragments, the existence of a 
constitutional dyscrasia, insufficient nourishment, and prolonged confine- 
ment to bed. The patient should be encouraged to get into the sunlight 
and the open air. Remedies taken internally have not fairly established 
a claim to confidence. The phosphates and magnesia have been fre- 
quently administered, and mercury, pushed to salivation, has been 
credited w T ith several successes in non-syphilitic cases. Its systematic 
use is of course indicated in patients presenting the specific taint. 

As a means of stimulating the nutrition of the limb, and thus promot- 
ing the growth and consolidation of the callus, I should try the descend- 
ing constant current, the influence of which in this direction has been 
amply demonstrated. 1 I have met with only one instance of its use in 
pseudarthrosis, Broca's case referred to in Bognaud's thesis (see p. 
203)', and in this it seems to have been used only for the purpose of 

1 Onimus & Legros, Traite d'Electricite Medioale, 1872. 
14 



210 



PSEUDARTHROSIS AND DELAYED UNION 



restoring their functions to the disabled nerves. Gurlt refers to three 
cases in which electricity was used, but does not state whether it was the 
interrupted or the constant current. Apparently it was used as a local 
irritant. 

Local measures have been employed in great variety, but with only 
two special objects : first, that of producing a more or less severe local 
irritation at the fracture or in its neighborhood, with the hope of thereby 
stimulating the reparative process ; and, second, restoring the parts by 
an operation to the condition of a recent but compound fracture. 

The first method finds its simplest form in the application of irritants 
to the surface of the limb over the fracture ; the tincture of iodine, 
blisters, and issues have been used, and successes have been claimed for 
each, but it seems probable that the cure was due mainly, if not entirely, 
to the immobility in which the limb was kept during the treatment. 

Irritation of the seat of fracture, of the callus, or of the ends of the 
bones is produced in a great variety of ways, some mechanical, others 
operative. Direct pressure with a tourniquet or graduated compresses 
has been used, especially in cases where the fragments have not been 
properly immobilized, and a large but soft callus has formed; in angular 
displacement it is used to restore at the same time the proper direction 
by pressure upon the projecting angle. Slight but frequently repeated 
irritation in non-union of the lower extremity is obtained by making 
the patient walk while the limb is protected from mobility or angular 
displacement by a snugly fitting apparatus. This may be one of the 
immovable dressings, or, better, an apparatus of leather and iron made 
to fit very accurately. Such a one, devised by 
Prof. H. H. Smith, of Philadelphia, is represented 
in figs. 118 and 119, and has yielded several 
cures. The objection to it is that the amount of the 
irritation, being under the control of the patient 
rather than of the surgeon, may be excessive, and, 
especially if accompanied by some mobility, may 

Fig. 119. 





H. H. Smith's splint foi 
ununited fracture of the 
thigh. 



H. H. Smith's splint for ununited fracture of the leg. 



lead to more or less absorption of the callus, and 
thus be harmful rather than beneficial. 

Violent friction of the ends by seizing the frag- 
ments, one in each hand, and rubbing them against 
each other not only sets up a certain degree of 
irritation, but also ruptures fibrous bands, and 
may tear off similar coverings from the ends of 



PSEUDARTHROSIS AND DELAYED UNION. 211 

the bone and thus restore it partially to the condition of a recent frac- 
ture. The plan is an ancient one, and has furnished many cures. It 
needs to be repeated on several successive days until the seat of the 
fracture becomes tender and swollen, and then the limb must be care- 
fully immobilized. 

Complete rupture of the fibrous bands uniting the fragments is, ac- 
cording to Gurlt, one of the best and least dangerous measures that can 
be employed. It is most suitable in those cases in which the bone is 
united by dense fibrous tissue, especially if there is overriding. An- 
aesthesia is required. The patient is so placed that the lower fragment 
projects entirely beyond the edge of the bed or table, and then it is 
pressed forcibly downwards until the tissues are felt to crack and the 
lower part of the limb is brought to a right angle with the upper. 'It is 
then bent to the same distance in the opposite direction, and moved freely 
about until the surgeon is assured of its complete mobility, after which 
it is treated as a recent fracture. Such force as can be exerted by the 
hands of the surgeon is usually sufficient, but instruments may be re- 
quired, especially to obtain the necessary extension. Gurlt says that 
the procedure, violent as it seems, is not followed by much reaction, and 
that suppuration is not to be feared. On the contrary, the reaction is 
sometimes insufficient to result in the formation of a callus. He prefers 
it to the milder method of simple permanent extension, which has been 
much employed in ununited fractures of the thigh with overriding. 

Subcutaneous scarification of the ends with division of the fibrous bands 
has been used with the same object, but apparently with much less 
success, and has now been practically abandoned ; and long fine needles 
have been thrust between the fragments and left in place for some time 
in order to provoke the desired reaction. This latter plan is sometimes 
very difficult of execution on account of the irregularities in the line of 
fracture. Malgaigne, 1 apparently, was the first to try it, in 1847, but 
although he made thirty-six attempts to pass the needle, all failed, and 
in the ten years that elapsed before the publication of his book he does 
not seem to have tried it again. He reports a success by Wiesel. 

Irritation by galvanic currents has been used in connection with acu- 
puncture ; Agnew's tables contain five cases of fracture of the leg thus 
treated successfully. 

The seton, passed between or beside the fragments, appears to have 
been employed once or twice toward the end of the last century, but its 
introduction as a method of treatment is undoubtedly due to Physick, of 
Philadelphia, who, in 1802, cured by this means an ununited fracture 
of the humerus. He first made extension to bring the fragments 
into place and then passed a silk ribbon between them and left it 
in place until consolidation seemed nearly complete five months after its 
introduction. Subsequent operators left the seton in for a much shorter 
period, and some, including Physick himself, found it occasionally neces- 
sary to aid its passage by a preliminary incision down to the bone. 
Norris's table gives 46 cases with 36 recoveries and 2 deaths thus dis- 
tributed : — 

1 Loc. cit., vol. i. p. 307. 



212 PSEUDARTHROSIS AND DELAYED UNION. 

Bone. Cases. Cures. Deaths. 

Femur .13 9 1 

Leg . ; 10 10 

Humerus ...... 16 10 1 

Forearm . 6 6 

Jaw ■ . 1 1 

Malgaigne adds to this list other cases not included in it, but mentioned 
in the paper, and also, apparently, the 15 instances in the table in which 
it is mentioned in the column of " methods which had previously failed," 



and constructs the following table theref 


rom : 


— 






Bone. Ca^-es. 


Cures. 


Failures. 


Deaths. 


Humerus 


30 


13 


16 


1 


Femur 


18 


9 


8 


1 


Leo; or tibia ..... 


14 


13 


1 




Either or both bones of the forearm 


6 


6 






Clavicle 


2 


2 






Jaw ....... 


1 


1 






Acromion ..... 


1 









72 44 25 3 

Agnew's table contains 73 cases ; 28 were cured and 8 relieved ; 34 
were failures, 2 died, and of 1 the result was not known. The two 
deaths appear to be those of Norris's table. Gurlt's analysis of his own 
table contains 143 instances of the use of the seton, including only the 
arm, forearm, thigh, and leg, with 68 cures, 10 improved, 59 failures, 3 
deaths, and 3 unknown results. The 3 deaths were after operations upon 
the thigh (2) and arm (1), in 32 cases of the former and 68 of the latter. 
Agnew's table, although certainly prepared as late as 1875, contains 
only 10 cases reported since 1859, and only 3 of these since 1864 
(1865-68), a fact which may be taken as an indication that the method 
is falling into disuse. I have not seen or heard of a case in the last ten 
years. Norris speaks of it as " one of the safest, least painful, and 
most effectual of the numerous operations that are performed for the 
cure of pseudarthrosis," but adds that the separation or direction of the 
fragments, or the abundant deposit of callus may prove an insurmount- 
able obstacle to its use. In noticing this statement Gurlt points out very 
properly not only that these obstacles exist in a considerable proportion 
of cases, but also that the records of the operation do not entirely bear 
out Norris's estimate of its safety and efficiency, and that the largest 
proportion of failures is found after its use upon the humerus. An ex- 
amination of the recorded cases shows that the dangers are increased, 
while its efficiency is not, by the prolonged retention of the seton ; there- 
fore, if used, it should be withdrawn as soon as a sufficient degree of 
irritation, for the recognition of which, unfortunately, no rule can be 
laid down, has been set up, probably, in about a week. 

Perforation of the ends of the bone was first employed by Dieffenbach 
in 1841, but after trial in two cases, one of which was cured and the 
other improved, was abandoned by him for the insertion of ivory pegs. 
It was then suggested to Detmold 1 by a reverse process of reasoning 

1 Oral Communication. 



PSEUDOARTHROSIS AND DELAYED UNION. 213 

after the publication of Dieffenbach's successes with the ivory pegs, and 
successfully used by him September 4th, 1850, 1 and again, he tells me, 
shortly afterwards in the presence of a committee of the New York 
Academy of Medicine. The method, however, is commonly associated 
with the name of the late Prof. Brainard, of Chicago, who forced it upon 
the attention of the profession in various articles. 2 The theory of the 
method is that the perforation of each fragment at one or more points 
near the line of fracture is sufficient to excite the desired productive 
osteitis without danger of suppuration. Brainard used a triangular 
pointed drill made of very hard steel, and placed the limb during the 
operation in a short metal splint perforated at various points. The drill 
was passed through one of these perforations and prevented from pene- 
trating too deeply by a sliding clamp which could be fixed by a thumb- 
screw at any desired point on its shaft. He recommended that after the 
drill had been forced well into or through the bone it should be partly 
withdrawn and made to penetrate again at another point or in a different 
direction. 

Agnew's table contains 51 cases thus treated: 32 were cured, 2 im- 
proved, and in 17 the operation failed. 



Bone. 


Cases. 


Cures. 


Improved. 


Failu 


Humerus . 


. 14 


6 


1 


7 


Radius and ulna 


7 


4 




3 


Femur 


. 8 


5 




3 


Tibia and fibula 


. 19 


14 


1 


4 


Patella 


. 1 


1 






Inferior maxilla 


2 


2 







So far as I am able to judge, the operation is regarded favorably by 
American surgeons, and is among the first of the operative methods em- 
ployed in any given case. It is unsuited to cases in which there is much 
irreducible longitudinal displacement. In the cases in which I have 
seen it used but little force has been required to perforate the bone. In 
a case reported by Dr. Weir, 3 in which a drill with a flattened point was 
used, the point of the instrument broke and remained in the bone ; the 
patient died of erysipelas, apparently originating in an abrasion of the 
skin. 

In 1846 Dieffenbach treated successfully an ununited fracture of the 
humerus by inserting an ivory peg into each fragment half an inch from 
its end, and leaving them in place for two weeks. The plan was based 
upon the knowledge obtained by experiments upon animals that the pres- 
ence of a foreign body in bone provokes an abundant formation in its 
neighborhood. The operation is done by passing a narrow-bladed knife 
directly down to the bone and following it with a gimlet or drill, which 
is then made to perforate the bone completely. A cylindrical peg of 

1 This case is reported in the New York Med. Gazette, 1850, p. 232. The fracture 
was of the tibia, and two holes were bored transversely, and one obliquely upwards, 
the latter beginniug 1^ inches below the fracture and penetrating the upper fragment 
for an inch or more, rfandford is also referred to by Brainard assh-aving perforated 
the bone before 1850, but his operation (Trans. Am. Med. 'Association, 1850, p. 355) 
was simply division of the fibrous bone with a tenotome. 

2 The principal one is in the Transactions of the Am. Med. Association, 1854, p. 
557. Thirteen cases were reported by him in the Chicago Med. Journal, Sept. 1858. 

3 New York Med. Record, March 8, 1879, p. 235. 



214 PSEUDARTHROSIS AND DELAYED UNION. 

ivory, slightly smaller than the gimlet, is oiled and driven into the open- 
ing until it projects about half an inch on the opposite side. The other 
fragment is treated in the same manner, a dressing of oakum or lint 
placed over the incisions, and the pegs, the ends of which are left pro- 
jecting above the surface, withdrawn after deep pain begins to be felt in 
the bone. If the tissue between the fragments is lax it must be lacerated 
by incision, or by free movements. 

The operation exposes to the chance of excessive suppuration and 
other accidents of compound fracture. Gurlt's 21 cases of the opera- 
tion and its modifications show no deaths and 14 cures ; Agnew's 58 
similar cases give 1 death and 36 cures. 

The modifications consist mainly in the substitution of metal for the 
ivory pegs, and in sometimes using the peg to fasten the fragments 
together by driving it through both. Occasionally the pegs have been 
cut off level with the bone and the wound left to close over them. Under 
these circumstances the ivory pegs become eroded, and may disappear 
entirely by absorption or become encysted. 

Trendelenburg exhibited at the Tenth Congress of the German Gesell- 
schaft fur Chirurgie 1 a specimen of pseudarthrosis of the lower end of 
the femur which had been cured by the introduction of an ivory peg 
through the knee-joint. At the death of the patient, two and a half 
years afterwards, the peg was found unchanged, except by the separa- 
tion of the end which had been left projecting into the joint, and which 
w T as found imbedded in the capsule. At the same meeting Riedinger 
exhibited preparations to show the superiority of bone pegs to those 
made of ivory. The bone pegs apparently became structurally united 
with the bone into which they were introduced. 

Caustic potash has been applied with success to the ends of the bones 
after division or removal of the intermediate fibrous tissue ; the applica- 
tion is continued until a black slough forms, and is repeated if necessary. 
The actual cautery has been used in the same manner. 

Resection of the end of one or both fragments was first performed for 
the relief of pseudarthrosis in 1760 at the suggestion of White of Man- 
chester, and is said by Gurlt to have been, with the exception of the 
seton, the method most frequently resorted to. It owed this favor doubt- 
less to its radical character, to the promise it held out of speedy union 
by restoration of the parts to the condition of a recent fracture and 
their accurate coaptation ; but its dangers, which were those of com- 
pound fracture, proved so great that many surgeons hesitated to employ 
it, and Sir Benjamin Brodie condemned it entirely. The great reduc- 
tion of these dangers by the use of antiseptic dressings has again brought 
it into favor, and the journals now contain comparatively frequent re- 
ports of its use. The operation consists in the division or excision of 
the intermediate fibrous band, and the freshening of one or both frag- 
ments by the saw or chisel, and sometimes in the fastening of them 
together by a wire suture or ligature, or by transfixion with pins of 
ivory or metal. 

A longitudinal incision is made over the fracture on the side that per- 

1 Supplement to Centralblatt fur Chirurgie, 1881, No. 20, p. 21. 



PSEUDARTHROSIS AND DELAYED UNION. 215 

raits the easiest access to the bone with avoidance of the main vessels 
and nerves, and is carried down to the bone by drawing the muscles 
aside, or by cutting through them if necessary. The uniting band is 
divided or stripped oif, each end turned out, and its surface freshened 
with the saw or bone-pliers, the fresh surfaces- being so shaped as to 
favor their subsequent coaptation to the greatest possible extent. If the 
bone is covered by thick masses of muscle, or if the fracture is near a 
joint it is not always easy or even possible to turn out the ends, and then 
the freshening must be done with a chain-saw, metacarpal saw, or chisel. 
The periosteum should be preserved to favor the formation of an exter- 
nal callus, but it does not seem desirable to carry this to the extent 
practised in one or two cases of stripping up a sleeve of periosteum from 
each end and sawing off the corresponding parts of the bone, so that one 
sleeve can be engaged within the other. 

Only as much bone should be taken away as is necessary to thoroughly 
freshen the ends and make the desired coaptation possible ; but the loss 
of substance involved in this removal is less important in the upper than 
in the lower extremity. 

If the surgeon desires to fasten the bones together he may surround 
them with a loop of wire, if the line of contact is sufficiently oblique, or 
perforate them with a drill and pass a wire through the holes thus made. 
The fragments are brought close together and fixed by twisting the wire, 
or by passing a canula down over its ends to the bone and fixing them 
by twisting on the outside. Or the ends of the wire may be cut short, 
if antiseptic dressings are used, and left to become encysted. If the line 
of fracture is oblique, a metal peg or screw may be driven through one 
fragment into the other. The wire or pin should be left in place for a 
length of time that varies with the size of the bone and the consequent 
rapidity of repair, but, as a general rule, it may be removed in the course 
of two or three weeks. The wire is removed by untwisting it and draw- 
ing it out, a procedure which is sometimes difficult. MacOormac has 
sought to obviate this difficulty by passing a stout pin through the bones 
and placing the wire in the form of a figure-of-eight over its two ends ; 
by the withdrawal of the pin the wire is freed. 

Yolkmann 1 treated a pseudarthrosis of the tibia with much overriding 
by notching each end for two inches and fastening them together by 
means of two ivory pegs, as shown in fig. 120. A gypsum splint was 
applied and the wound treated antiseptically ; it healed promptly down 
to a small fistula, and the pegs which had then become loose and eroded 
were withdrawn in the seventh week. No mobility could be detected 
at that time, and the patient was dismissed cured four weeks afterwards, 

In one case Roux sought to immobilize the fragments by sharpening 
one and forcing it into the medullary canal of the other, and apparently 
with success ; but unfortunately the patient had a fall two months after- 
wards and broke the arm again, after which amputation became necessary. 
Hamilton says he has done the same, but does not state the result Holt- 
house 2 tried it unsuccessfully. 

1 Berlin. Klinischer Wochenschrift, 1875, p. 221. 

2 Lancet, 1864, i. p. 326. 



216 



PSEUDARTHROSIS AND DELAYED UNION. 



The indications which determine the choice of a method of treatment 
have been pointed out in connection with the different methods, and they 
vary so greatly with the pathological conditions of the fracture that it is 
hardly possible to summarize them profitably except in the most general 



Fig. 120. 




Volkmann's operation for pseudarthrosis. 

terms. As a rule, the milder methods are to be preferred in all cases in 
which there is reason to consider the case as simply one of delayed 
union, and these measures must of course be directed to removing the 
cause of the delay, whether it be a general or constitutional vice or a 
local obstacle, such as mobility or displacement. In addition, local irri- 
tation by friction or by perforation with a drill may properly be used. 
Resection, I believe, may be stripped of most of its danger by strict an- 
tiseptic precautions, and in cases of real pseudarthrosis and disease of 
the fragments it is the only method that holds out much prospect of 
success. 

Palliative measures consist in the application to the limb of an appa- 
ratus that will supply the necessary solidity. Such an apparatus must 
ordinarily consist of a snugly fitting leather case, possibly strengthened 
by longitudinal strips of metal. 

Amputation may be required to save the patient's life after the failure 
of an operation to cure the pseudarthrosis and the occurrence of profuse 
suppuration or gangrene ; or it may be demanded by the patient as a 
relief from a painful and burdensome limb, especially if the non-union is 
associated with necrosis or caries and interminable suppuration. 



DEFORMED, FAULTY, OR VICIOUS UNION. 



21 



CHAPTER X. 



DEFORMED, FAULTY, OR VICIOUS UNION. 



Fig. 121. 



Besides the temporary and permanent causes already mentioned 
which may interfere with the functions of a limb that has been broken, 
there are others yet to be considered which depend upon the irregular 
union and position of non-articular portions of the bone, upon the ex- 
cessive size of the callus, or upon the inclusion in the latter of muscles 
or tendons. 

The inclusion of a muscle or tendon in a callus is not a common com- 
plication, and most of the recorded instances have been in the forearm 
or leg. The following case is a note- 
worthy example: Chassaignac 1 pre- 
sented a specimen of fracture of the 
radius and ulna with complete fusion 
of the bones. The pronator quadratus 
was atrophied, and pronation and supi- 
nation abolished. The extensors of 
the index finder were transformed into 
a fibrous band attached to the callus. 
One of the extensors and one of the 
flexors of the little finger were fixed 
in like manner and interrupted at the 
callus. 

It is possible that in the earlier 
stages of the less severe cases of this 
character the muscles or tendons might 
be successfully and safely freed by an 
operation under the antiseptic method, 
but if the tissue has itself become ossi- 
fied nothing can be hoped for from any 
treatment. 

Mention has been made in Chapter 
VII. of the inclusion of a nerve within 
a callus, and of the possible pressure 
of an exuberant callus upon the nerves 
that pass over it. It seems probable 
that the latter is not a sufficient cause 
of the pain that is experienced in such 
cases, but must be aided by previous 

. . ' J f \icious union after fracture of the femur. 

injury to the nerve resulting in a neu- (Gurit.) 




1 Bull, de la Soc. Anatomique, 1842-43, p. 339. 



218 DEFORMED, FAULTY, OR VICIOUS UNION. 

ritis which is kept up perhaps by the pressure. Usually when an over- 
grown callus produces disability, it does so by establishing firm union 
with an adjacent bone, or by opposing a fixed mechanical obstacle to the 
motions of a joint. Common examples of the former are furnished by 
fractures of the' forearm, and an extreme one of the latter is represented 
in figure 121. It is taken from a specimen of fracture of the shaft of 
the femur united with much shortening. Movements at the hip-joint 
were entirely prevented by a bridge of bone uniting the pelvis with the 
seat of fracture. 

The most frequent kind of vicious union, and the one commonly re- 
ferred to when this term is used, is that in which the fragments are 
united with a degree of displacement that interferes seriously with the 
form and functions of the limb. It is convenient for the present purpose 
to divide this pathological group into two principal varieties, differing in 
their anatomical characteristics and in the nature of the resulting disa- 
bility, according as the fracture involves the shaft or the articular end 
of a bone. Of these, only the former will be here considered ; its examples 
present a certain degree of uniformity in their elements and treatment, 
while the latter can be better considered in detail and in connection with 
the different fractures. 

Vicious union of the shaft of a long bone is union with angular, longi- 
tudinal, lateral, or rotatory displacement to an extent which causes a 
notable deformity or diminution of function. It is most important, most 
likely to require surgical treatment, after fracture of the leg or thigh, 
because changes in the length or shape of the lower extremity are more 
commonly productive of functional disabilities than similar changes in 
the arm, and more amenable to treatment than those of the forearm. 

This disability may be due not only to shortening or rotation of the 
limb, but also to change in the direction of the long axis of the lower 
segment which makes it necessary to evert the foot in order to bring the 
sole fiat upon the ground, and thus the internal lateral ligament of the 
ankle is exposed to an excessive and constant strain. Or the weight of 
the body may cause pain at the seat of fracture by increasing the ab- 
normal angle existing there, or the point of a fragment may irritate the 
soft parts and cause persistent ulceration. 

The causes are the same as those Avhich produce displacements, for 
the condition is simply the persistence of a displacement produced at the 
time of the accident, and left unreduced, or occurring in the course of 
the treatment as the result of defective contention, of too early use of 
the limb, or of insubordination on the part of the patient. 

Of 149 cases collected by Gurlt of vicious union requiring an opera- 
tion for its correction 71 were of the thigh, 59 of the leg, 12 of the arm, 
and 7 of the forearm. Of the fractures of the thigh which resulted in 
it the position was indicated in 56 ; in 20 of these it was in the upper 
third, in 10 above the middle, and in 21 at the middle. The character 
of the displacement was indicated in 55 ; in 38 of these it was angular 
with the convexity directed outwards or outwards and backwards, and in 
9 outwards and forwards. Of 37 fractures of the leg in which the loca- 
tion of the fracture is mentioned, 18 were in the lower third and 8 below 
the middle; of 8o in which the direction of the apex of the angle formed 



DEFORMED, FAULTY, OR VICIOUS UNION. 



219 



by the displacement is given, it was forwards in 18, outwards in 8, and 
inwards in 7. 

In 3 cases in which badly united fracture of the fibula led to operative 
interference, the symptoms were : a depression above the external malleo- 
lus, marked prominence of the internal malleolus, increase of the distance 
between the two, and extreme eversion of the sole of the foot ; and in 
one case the astragalus had slipped up between the bones of the leg. 
When this displacement is associated with bony ankylosis of the ankle- 
joint (figures 122 and 123) it cannot be corrected, and the only treat- 
ment is resection or amputation. 



Fi<?. 122. 



123. 





Vicious union after fracture of the fibula. 



Vicious union after fracture of the fibula 2% 
inches above the tip of the malleolus. 



The methods of treatment present four varieties: 1st, the straighten- 
ing of the limb by immediate infraction or bending of the callus, or 
gradually by a moderate force constantly applied ; 2d, forcible rupture 
of the callus ; bd, division of the callus ; 4th, resection of projecting 
portions of the bone. 

1. Infraction or Bending of the Callus. — Bending of the callus at a 
single sitting is possible only before complete ossification has taken 
place, but gradual bending and straightening by a moderate force acting 
constantly can be accomplished even after three or four months. This 
method is only the later application of that inspection and correction 
which was recommended by the older surgeons to be made when neces- 



220 DEFORMED, FAULTY, OR VICIOUS UNION. 

sary in the course of any case, and has been practised from the earliest 
days. The operative procedure in the rapid form consists of extension, 
counter-extension, and coaptation, the latter being made by pressure 
upon the prominent angle by the hands alone, or with the aid of the 
knee. If the angular displacement is associated with overriding exten- 
sion is necessary both to reduce the displacement and to maintain the 
reduction when obtained. The operation is simply the reduction of a 
displacement while the callus is still incomplete, and after this is. done 
the usual precautions are still to be taken to secure immobility in a good 
position. 

Gradual bending is accomplished either by extension and counter- 
extension in the usual manner, or by constant lateral pressure upon the 
projecting angle. Two principal methods of exerting the latter are in 
use : a splint is applied on the open side of the angle and the limb is 
bound to it by a circular roller or bands tightened several times each 
day, or by elastic bands ; or the splint is applied upon the convex side 
and the distal segment of the limb drawn towards it by the same means. 
Careful padding is needed at all points of pressure. This method is apt 
to be painful, and is inferior in most cases to the rapid method done, if 
necessary, with the aid of anaesthesia. 

The change in the direction of the bone is accompanied by the break- 
ing of some portions of the callus, and the difference, therefore, between 
this and the second method, in which the callus is completely broken, is 
one of degree rather than of kind, and the surgeon in attempting either 
may find his object accomplished by the other. 

u l. Rupture of the Callus. — This method, which appears to have been 
used in very early times, is mentioned, according to Malgaigne, by the 
earlier writers only to be condemned because it was feared the bones 
would break at other than the points desired. Toward the end of the 
17th century, Purman 1 used a machine for the purpose, but his example 
seems to have had no followers until in 1782 or 1783 Bosch found an 
old iron apparatus which appeared to have been made for this purpose. 
He had another constructed in a modified form and used it successfully 
upon two cases in 1783, one of them being a fracture of the femur in 
the twenty-eighth week, the other a fracture of the leg. He repeated 
the operation a number of times, and once, in 1811, in the presence of 
Oesterlen, who repeated it in 1817 and published the case together with 
several of Bosch's. 

Bosch's original instrument was like a book-binder's press ; he modi- 
fied it a number of times and many instruments have since been devised 
by different surgeons. They are known as osteoclasts, and the force is 
usually exerted by means of a screw. One of the simplest, Rizzoli's, 
consists of a stout steel bar supporting a pad in the centre and a ring at 
each end, all movable upon it. The limb is passed through the rings 
which are then fixed at the selected points, and the intermediate pad is 
screwed down upon the bone at the point where the fracture is to be 
made. A very powerful instrument capable of accurate adjustment has 

1 Grosser nnd ganz nen gewundener Lorbeer-Krantz, oder Wund-Artzney, 1692. 
Quoted by Grurlt. 



DEFORMED, FAULTY, OR VICIOUS UNION. 221 

been made by Collin & Co., of Paris, for the purpose of making supra- 
condyloid fracture of the femur for the relief of genu valgum, and could 
probably be used with advantage also' in cases of vicious union. 1 Prof. 
Sauds 2 speaks highly of the accuracy and certiiaty wish which it pro- 
duces its results. 

The injuries inflicted in the rupture of a callus are less than those ac- 
companying an ordinary fracture, because the force required to effect it 
is less and is applied in such a manner that it does not cause displace- 
ment and laceration of the soft parts. It has already been shown that 
when fragments are united with much displacement, which is the condi- 
tion in vicious union, the callus is usually comparatively scanty and 
remains friable for a considerable time, and experience has shown that 
secondary fractures produced intentionally or by accident heal, as a rule, 
more promptly and with less reaction than primary fractures. Of the 
numerous cases collected by Gurlt there was but one in which suppura- 
tion occurred, and in that the ultimate result was good, and only one in 
which subsequent union failed. Malgaigne, on the other hand, refers to 
three cases in which death followed the operation. In the first, per- 
formed by Ali Rodoham, the patient, a man 70 years old, appears to 
have died upon the table ; in the second, reported by Morgagni, the 
patient died of the remoter complications of the fracture ; and in the third, 
reported by Laugier, death took place an hour and a half after the ope- 
ration. 

Gurlt gives a table, made up of cases collected by him, in which the 
callus was ruptured, with or without the aid of instruments, after the 
lapse of the period of time which is usually sufficient for complete con- 
solidation, that is, ten weeks for fractures of the thigh and eight weeks 
for those of the leg. It is arranged in two groups according to the age 
of the patients, those under fifteen years composing one, all older ones 
the other. The cases show, as he points out, that forcible rupture is a 
successful and safe method of treatment, even after the lapse of a period 
of time that has often been considered an absolute contraindication. In 
10 of the adult cases more than six months had elapsed, the longest 
period being twenty-one months, and the same length of time in 8 of the 
younger cases, in 3 of them two years, and in 2 one year. The average 
age of the adult cases was thirty-three years, that of the young cases 
about seven years, the oldest being sixty-four, the youngest one and a 
half; 27 cases were of the thigh, 22 of the leg, and 6 of the humerus. 

The various kinds of medical treatment which have been suggested or 
employed, with a view to softening the callus and making its rupture 
easier, have no effect beyond causing the loss of valuable time, and the 
perforation of the callus at several points with a drill for the same pur- 
pose seems not to be of sufficient value to compensate for the additional 
risk. Gurlt's table contains 4 cases in which this latter was done ; two 
were successful, in one the fracture could not be produced, and in the 
remaining one suppuration ensued and caused death. If the drill is used 
the wounds should be allowed to heal before the callus is broken. 

1 For an instance of its successful use to relieve faulty union at the ankle, see Bull, 
de la Societe de Chirurgie, 1880, p. 419, or chapter xxvii. of this book. 

2 Proceedings of N. Y. Surgical Soc, May 10, 1881, in the Medical Record. 1881. 



222 DEFORMED, FAULTY, OR VICIOUS UNION. 

The operation consists either in extension and counter-extension by 
the hands of the operator and his assistants, or by specially contrived 
instruments, or in lateral pressure with the hands and knee, or with the 
limb resting on a table so that the weight of the surgeon's body can be 
used as the rupturing force, or in the use of the osteoclast. Usually 
lateral force is exerted upon or near the apex of the angle, that Is, in 
the direction in which it tends to diminish the displacement, but Dieften- 
bach has recommended that it should be exerted at first in the opposite 
direction, increasing the angle, as is often done in cases of ankylosis. 
As soon as the surgeon is made aware by the sound or the mobility that 
the callus has been broken he reduces the displacement as gently as pos- 
sible by traction or lateral pressure, and when this reduction is complete, 
or has been carried as far as is considered prudent, he applies the 
dressings. 

I find no mention made by the authors of rupture of the main arteries 
or nerves during this operation, and yet it seems a not impossible acci- 
dent when the deformity has lasted a long time and these organs lie on 
the side of the concavity. 

In this connection may be mentioned also an operation proposed and 
performed by Rizzoli in 1347, that of fracturing the corresponding bone 
of the other limb and seeking its union with a shortening equal to that 
of the first. The idea appears to have been suggested to Rizzoli, two 
or three years before, by a case of fracture of the right femur of a man 
whose left femur had been broken twenty years before and had united 
with two inches of shortening. The new fracture was left without sup- 
port until its shortening equalled that of the other, and then it was 
placed in a fixed apparatus and allowed to unite in that position. The 
patient was afterwards able to walk without limping. 

A similar case had been treated in the same manner at Brussels in 
1840, and a shortening of three inches thus compensated for. 

I am not aware that Rizzoli's operation has ever been repeated, and it 
does not seem probable that many surgeons would be willing to recom- 
mend this means of correcting an inequality in length which could be 
sufficiently well met by a cork sole. 1 

8. Division of the Callus. — This method differs from the preceding 
one, in that it substitutes a compound fracture for a simple one. It con- 
sists essentially in an incision through the soft parts down to the bone 
and the division of the latter by a saw, chisel, or bone-pliers. Accord- 
ing to Malgaigne it was first performed by Paulus iEgineta, and is re- 
ferred to by Hildanus as having been performed by a surgeon of his 
time. Malgaigne mentions nine additional cases, two of simple division, 
and seven of resection, and Gurlt gives in his table thirty-eight cases, 
about half of which antedate the publication of Malgaigne's book. 

So far as the essence of the operation is concerned, it is immaterial 
whether the bone is simply divided or a wedge-shaped piece removed ; 
the additional danger in the latter case is due to the greater laceration 

1 A well-known New York surgeon, however, about fifteen years ago excised four 
inches of the shaft of a sound femur in order to make the length of the limb the same 
as that of the opposite one, which had been shortened by excision of the hip-joint. 
This case also remains unique. 



DEFORMED, FAULTY, OR VICIOUS UNION. 223 

of -the soft parts. This is a detail which depends upon the character of 
the displacement and the form of the callus. Langenbeck modified the 
procedure by using a very narrow saw for the division of the bone. He 
first made an incision about half an inch long, through which he intro- 
duced a drill and perforated the bone ; he then passed the saw into the 
hole, and cutting first in one direction and then in the other, divided 
the bone almost entirely. After the wound thus made had filled with 
granulations, he fractured the bone at the weakened point and reduced 
the displacement. 

Within the last four or five years many osteotomies have been per- 
formed upon the curved bones of rachitic children, and upon the femur 
in cases of genu valgum under antiseptic precautions with an almost 
entire absence of dangerous accidents or complications. The method of 
procedure is to make a short longitudinal incision down to the bone, in- 
sert a chisel, turn it transversely, and divide the bone by repeated blows 
with a heavy mallet, the limb resting meanwhile upon a sand-bag. The 
wound is then syringed out with a 2 j- per cent, solution of carbolic acid, 
dressed with carbolized gauze, and the limb placed in a splint. Usually 
the dressing does not need to be changed, and the wound heals by pri- 
mary union. If the cellular tissue projects through the incision in the 
skin it should be cut away below the level of the latter so as not to inter- 
fere with its union. It is recommended also, that the sides of the wound 
should be kept in apposition by a narrow strip of adhesive plaster crossing 
its centre. The uncovered portion of the wound provides for the escape 
of any discharge. 

I have not met with any case in which this method has been applied 
to a badly united fracture, although Malgaigne 1 proposed it as less dan- 
gerous than division with a saw, but I feel sure it would be equally 
serviceable in cases of angular or rotatory displacement without such 
overriding as would greatly increase the thickness of the bone at the 
point where the fracture would have to be made. 

In long- standing cases in which the disability is due more to the de- 
fleeted position of the foot than to the shortening, as in some badly 
united fractures of the leg, and when the principal indication, therefore, 
is merely to correct the faulty direction of the lower segment, and in 
similar cases of extreme angular displacement of the thigh in which there 
is reason to suppose that the tissues on the concave side have become 
permanently shortened, it is better to resect a V-shaped piece, or even 
a piece of considerable length, than simply to divide the bone, so that 
the limb may be made straight without undue or dangerous tension of 
the soft parts. 

In view of the great diminution of dangers by the use of the antiseptic 
methods, the tabulation of the results obtained under the other methods 
of treatment does not seem necessary, or even useful. It is sufficient to 
say that the 38 cases collected by G-urlt give 25 cures, 1 improvement, 
1 failure, 2 amputations, and 7 deaths, and in 2 the result is unknown. 

4. Resection of a Projecting Fragment. — In some cases the defect of 
the union is found not in shortening or change of the direction of the 

1 Loc. cit., vol. i. p. 339. 



224 



DEFORMED, FAULTY, OR VICIOUS UNION". 




Fig. 124. limb, but simply in the projection of the end of one of 

the fragments which by its pressure may irritate and 
cause ulceration of the skin, and be the source of much 
discomfort, or even disability. The same condition may, 
but much more rarely, be the consequence of an over- 
growth of the callus. It occurs most frequently after 
oblique fracture of the humerus or tibia (fig. 124). 

The indication is plain, and the treatment simple and 
free from danger. A -longitudinal incision is made 
over the projecting bone, and the latter freely exposed 
and then removed with the saw, bone-pliers, or chisel. 
The sides of the incision are then brought together and 
primary union sought except at the point where the 
drainage tube is left. 

In making a choice among these means of correcting 
vicious union the surgeon must be guided by two facts : 
1st, that a simple fracture is a lesion which does not 
practically involve any danger to the patient's life, 
while a compound fracture, notwithstanding the vastly 
improved results obtained under antiseptic treatment, 
must be considered as a much graver injury ; and 2d, 
that the less the length of the time that has elapsed since 
the receipt of the original injury the greater is the pro- 
bability of success by the milder methods. The first 
will lead him to employ the milder methods whenever 
there is any hope of succeeding by their aid ; the second 
will guide him in the choice between immediate or gradual straightening 
and forcible rupture, or, when taken in connection with the extent and 
character of the displacement, may force him to resort to the more 
dangerous division of the callus. 

In all cases in which not more than two months have elapsed, the first 
method holds out a good prospect of success, and it should be resorted 
to at once without losing any time in vain measures intended to soften 
the callus. In fractures with much displacement this period may be 
considerably lengthened, for these are the fractures in which repair 
takes place most slowly, and the callus remains soft or friable longest. 

When a choice can be made forcible rupture is to be preferred to 
division by the saw. One objection which has been urged against it, 
that of an alleged difficulty of producing the fracture at the desired 
point, has been shown to be unfounded. The instruments at our dis- 
posal enable the fracture to be made with great precision. Another 
objection, that of subsequent failure of the bones to unite, has been urged 
against refracture. There is, so far as I know, but one recorded instance 
of such failure, and the objection, if it be a valid one, is equally good 
against division. 

If division is chosen it must be performed with the strictest attention 
to the details of the antiseptic method ; and resection of a portion of the 
callus or of the bone must be made whenever there is reason to suppose 
that the tissues in the concavity of the limb are permanently shortened. 



Vicious union 
after fracture of 
the tibia. 



DEFORMED, FAULTY, OR VICIOUS UNION. 225 

Subcutaneous division of the tendo Achillis may take the place of this 
resection in some faulty unions of the leg with an anterior angle. 

I have no means of determining the extent to which surgical interfer- 
ence is justifiable in cases in which a callus has united the bones of the 
forearm and destroyed the function of rotation of the wrist. 

The resection of a projecting fragment or portion of callus is an easy 
and safe means of removing what may be the cause of serious discom- 
fort or disability, and the surgeon should not hesitate to do it when a 
plain indication arises. 



if) 



226 GENERAL PROGNOSIS 



CHAPTER XI. 

GENERAL PROGNOSIS. 

The prognosis after fracture involves consideration of the effects of 
the injury with respect to the prolongation of life, the preservation of 
the limb, its usefulness if preserved, and the period of time required for 
convalescence. The different factors in this prognosis have been con- 
sidered, many of them in detail, in the preceding chapters, and I shall 
therefore only group them here for a more convenient general view. It 
has been said recently by a prominent German surgeon that a fracture is 
now to be considered rather as an inconvenience than as a misfortune, 
but while the remark may contain an element of truth, it is far too sweep- 
ing. We have seen that the life of the patient may be endangered not 
only by a compound fracture of a limb but also by a simple one, and 
that in almost any case the functions of the part are liable to be crippled 
for a considerable period of time, and perhaps permanently. 

The prognosis varies with the age and condition of the patient, the 
character, position, and origin of the fracture, and the complications to 
which it may give rise. 

1st. The Patient.— Sex does not affect the prognosis. Age has a great 
influence upon it ; the younger the patient the better the prognosis. In 
children the bones unite more promptly, and usually with less permanent 
deformity, and compound fractures are less serious. But in fractures 
involving or in close proximity to joints the prognosis, qua function, is 
affected unfavorably by the strong tendency that exists during youth and 
childhood to excessive formation of callus when the displacement is not 
entirely corrected. On the other hand, if the injury is such as to call 
for excision of the joint the probability of a reproduction of bone suffi- 
cient to create a new and serviceable joint is good. In old people the 
prognosis is worse because in the more severe cases they are less able to 
recover from the injury, escape the complications, and bear the necessary 
confinement to the bed. The latter is an especially grave element in the 
prognosis which is further aggravated by the pain. Furthermore, their 
joints are more likely to become stiffened, and their tissues to remain 
engorged and rigid. They are also especially liable to certain fractures, 
such as those of the wrist and neck of the femur, which entail necessarily 
a greater or less degree of deformity or disability. 

The general condition of the patient seems to be without any very 
serious importance so far as the repair of the fracture is concerned ; 
even in those rare cases in which there is a congenital or acquired pre- 
disposition to fracture, the bones, as we have seen, unite within the 
usual period. On the other hand, the existence of a special dyscrasia 
such as syphilis or scurvy, or an acute intercurrent disease may delay 



GENERAL PROGNOSIS. 227 

or entirely prevent repair. Paralysis of the affected limb may or may 
not affect the process, according to conditions which have been elsewhere 
detailed. 

2d. The Fracture. — Fractures by direct violence are, as a rule, more 
severe than those by indirect violence, because in addition to those lesions 
which are common to both forms there is also in the former the bruising 
of the soft parts produced by the external force, and the consequent in- 
creased probability of suppuration. And when the violence is great, as 
in the passage of a car-wheel across a limb, the bone is usually com- 
minuted, the muscles torn, and the vessels and nerves bruised and lace- 
rated. In gunshot fractures the prognosis is especially bad as regards 
the preservation of life or limb, the duration of the treatment, and the 
functional consequences. They are frequently associated with injury to 
important vessels or nerves, the tissues traversed by the ball are so 
bruised that suppuration is practically inevitable, and as bones deeply 
placed are as liable to be thus broken as the superficial ones the chances 
of efficient drainage are less. In addition, the injury to the bone itself 
is more severe, for it is shattered, splintered, and usually fissured. 

Although improved methods of treatment have reduced the mortality 
after compound fracture the prognosis still remains much more serious 
than after simple fracture. Repair takes place more slowly, the patient 
is exposed to more numerous and more serious complications during its 
progress, and the functional disability is usually greater and more pro- 
longed. When such a fracture involved a large joint, as the knee, 
amputation was formerly considered almost inevitable ; we have now 
learned that the limb can often be preserved, sometimes even with a 
useful joint, sometimes only after excision, but the risk is always a great 
one and secondary amputation may be required. 

Fractures of some bones carry with them special risks because of 
their relations to important viscera, as fractures of the skull, the spinal 
column, the hyoid bone or larynx, the ribs, and the pelvis. 

Fractures of the short or spongy bones unite more promptly and usually 
with less deformity than those of the shafts of the long bones, and the 
same is true of the spongy ends of the latter except when the fracture 
enters the joint. Small bones heal more quickly than large ones, and 
the bones of the face more quickly perhaps than any others. The shafts 
of the long bones are attached to so many muscles, the tendency to con- 
traction of the latter is so constant, and the counteracting effect of the 
different groups upon each other is so completely annulled by the frac- 
ture of the lever that the probability of union with more or less dis- 
placement and shortening is very great. This result may give occasion 
to so much dissatisfaction on the part of the patient that it is important 
it should be known to be unavoidable under many circumstances. Its 
cause, as we have seen, may lie in conditions that are entirely beyond 
the control of the surgeon, and he must not be held responsible for the 
limitations of our art. The surgical section of the American Medical 
Association 1 meeting at Chicago in 1877 gave expression to this fact in 
formal resolutions adopted after discussion of the subject. They said: 

1 Transactions, vol. xxviii. p. 507. 



228 GENERAL PROGNOSIS. 

"It is the opinion of this Section that shortening in cases of fracture of 
long bones is the rule in practice, regardless of any of the plans of 
treatment now in use." 

A controversy ,. regrettable on account of the personal issues which it 
has raised, has been since carried on between two of our prominent sur- 
geons upon this point, and has brought out very plainly the fact that 
even if the resolutions may be considered too sweeping by some they 
express what is undeniably true in many cases, the impossibility of 
insuring union without shortening. The assertion that a good, even per- 
fect, result after fracture of the femur can be insured by making com- 
plete reduction under ether, and then so fixing the limb in an immovable 
plaster apparatus as to maintain the reduction until union has taken 
place will be accepted by all as the correct statement of a principle, but 
of one which unfortunately cannot always be embodied in practice. The 
action of the muscles is not the only cause of displacement, and even 
when it is the cause permanent extension will not always overcome it ; 
and, secondly, the plaster dressing does not furnish complete permanent 
extension, because of the absence of an upper fixed point of support. 

In superficial bones the displacement is more easily recognized, and 
for this as well as for other reasons the prognosis is somewhat better 
than after fracture of bones that are covered by thick layers of muscles. 
When the corresponding bones of both limbs are broken the surgeon 
loses the standard of length and form furnished in other cases by the 
uninjured limb ; but, except perhaps in the case of the femur, this loss 
is not serious. The fracture of one of two parallel bones has a better 
prognosis than that of both, because the remaining bone acts as a splint 
and subsequent union of the two bones by the callus is less probable, a 
union which entails great functional disability in the case of the forearm, 
but is without serious consequences in the leg or ribs. Fracture of a 
bone at two or more points is very likely to be followed by permanent 
shortening, because of the difficulty of restoring the intermediate frag- 
ment to its proper position. 

In articular fractures the prognosis must be guarded, for in addition 
to the functional losses that may be caused, there is also danger of sup- 
puration of the joint, of caries or necrosis, or of the production of a 
chronic synovitis, especially in the young and strumous. If the fracture 
is not comminuted and if the displacements can be reduced, recovery with 
almost complete preservation of function may be obtained, but such a re- 
sult is rare. In many cases, as in fracture of the neck of the femur or of 
the humerus, the displacement can be neither recognized nor corrected, 
and in others, at the same points, bony union is practically impossible, 
and although such patients may be able to use the limb with some comfort 
and freedom, the great majority are permanently and seriously crippled. 
Fractures of the patella and coronoid process of the ulna may be ex- 
pected to heal by fibrous union, and the degree of disability depends 
partly upon the length of the fibrous band. 

In fractures combined with dislocation of the same bone, the prognosis, 
with reference to function, depends largely upon the possibility of re- 
ducing the dislocation. When the fracture is situated upon the shaft at 
some distance from the joint the reduction of the dislocation under ether 



GENERAL PROGNOSIS. 229 

will usually present much more than the usual difficulty, and when the 
fracture is near the joint and the dislocated fragment is a small one it 
may be impossible to act upon it at the time, and the reduction must be 
made, if at all, after the fracture has united. , 

The less extensive the fracture, the better the prognosis. Infractions 
heal most quickly and with least tendency to displacement ; transverse 
fractures more quickly than oblique ones, because of the greater tendency 
of the latter to shortening and transverse displacement, Splintered 
fractures and fractures with long fissures involving the medullary canal 
are especially liable, if compound, to suppuration and to dangerous 
osteo-myelitis, and the former are exposed, as has been shown in Chap- 
ter VII., to the late formation of an abscess after apparent recovery. 

For the prognosis in the different complications which may arise in 
the course of the treatment the reader is referred to the sections speci- 
ally devoted to them. 



230 FRACTURES OF THE SKULL. 



CHAPTER XII. 

FRACTURES OF THE SKULL. 

This class of injuries, one of the most obscure and important in sur- 
gery, owes its special interest not to the lesion of the bone, but to those 
of the , brain or its coverings which are so frequently associated with it 
and lead so often to a fatal result. From the earliest times injuries of 
the head have been attentively studied with regard both to the mechan- 
ical questions involved in the production of fractures and to the treat- 
ment to be pursued. The coexistence of a wound of the soft parts has 
always been looked upon as a formidable complication, one which added 
to the dangers arising from pressure upon the brain those due to the 
contact of the air with the exposed parts, and therefore, as active interfer- 
ence could not be made in any case of simple fracture without creating 
this communication, the strong tendency of all surgeons in the last half 
century, I may say the positive teaching of all, was to temporize until 
the appearance of symptoms of intra-cranial inflammation should force 
the surgeon to attempt the removal of the actual or supposed cause. 1 In 
some cases the reaction was slight or entirely absent and the patients 
got well under this expectant plan ; in others the tardily undertaken 
operation failed to arrest the progress of the dangerous symptoms or 
seemed even to make it more rapid, and thus surgeons were confirmed 
in the policy of non-interference, not only in cases where there was no 
proof of fracture but also in others with both fracture and depression of 
the bone but without external wound. 

While such views were held concerning treatment, fractures of the 
skull were not to be separated practically from the larger class of in- 
juries of the head, and had but little in common with fractures of the 
limbs. But now the practice is changing under the influence of the 
improved methods of treating wounds, and even when a fracture is not 
compound many surgeons do not now hesitate to cut down upon the 
bone and apply the trephine if depression or even a fissure is found, so 
that it seems desirable to depart from the practice of former writers and 
include this class of injuries also among fractures. 

Fractures of the skull are by no means rare ; in the table of statistics 
given in Chapter I., there are 757 cases of this kind in a total of 51,398 
fractures. They occur in patients of all ages and both sexes, but are 
most frequent in adult males for reasons depending upon the greater 
exposure of that class of the community to the accidents and violences 
which are the most common causes of the lesion. These causes are 

1 Views radically opposed to this were held by some of the earlier surgeons, nota- 
bly Percy and Boyer, who advised the application of the trephine even in cases of 
simple contusion without fracture, as a means of preventing intra-cranial suppuration. 



FRACTURES OF THE SKULL. 231 

usually falls from a height or blows received from falling bodies or in 
personal encounters. 

The fractures of the vault are for the most part direct, that is, the 
bone is broken at the point where the blow is received ; fractures of the 
base may be indirect, or by transmitted violence, or may be due to the 
extension of a direct fracture of the vault. Some fractures of the base 
are caused by falls from a height upon the feet, knees, or buttocks, the 
force being transmitted to the base of the skull through the vertebral 
column, and in some exceptional cases of falls upon the head the frac- 
turing force is the momentum of the body impinging directly upon the 
base of the skull at the occipito-atloid articulation and crushing the 
bone as between a hammer and anvil. The term fracture by contre- 
coup has been much employed in the sense of " indirect fracture," the 
use originating apparently in an erroneous view of the mechanism by 
which the injury is produced. It was supposed that, the skull being 
globular in form and elastic in structure, a blow received at any given 
point of its surface might be so transmitted as to exert a fracturing force 
at the opposite or at some intermediate point. This view was supported 
by the fact that blows upon the head often cause extravasations of blood 
at distant points within it ; but it has been recently shown by Duret 1 that 
the mechanism of these extravasations is entirely different from that to 
which it was formerly attributed. He showed by well-devised experi- 
ments that when a violent blow is received upon the vault of the skull, 
with or without fracture, the sudden depression of the bone causes a 
wave of cerebro-spinal liquid to pass from the point that is struck and 
from the ventricles of the brain to the base, and this wave causes rupture 
of the meningeal and cerebral vessels by distension of the meshes of the 
pia mater and arachnoid during its passage and by the sudden diminu- 
tion of the extra-vascular pressure which follows its subsidence. By 
some surgeons the term fracture by contre-coup is applied only to cases 
in which the fracture occurs at a point diametrically opposite to that at 
which the blow is received ; by others its use is extended to those cases 
also in which the fracture is at any intermediate point ; and by others 
again, according to Duplay, to cases in which the head, being driven by 
the blow against some solid body, is fractured at the point which receives 
the second impact. This last use is clearly unjustifiable, for the fracture 
is a direct one. It is denied by some authors that cases of the first 
kind can exist, but, in view of two facts mentioned by Legouest and 
Servier, 2 I think the possibility must be admitted. These two facts 
were a fracture of the frontal bone produced by Perrin by throwing a 
skull forcibly upon its occiput, and a limited fracture of the occipital 
bone caused by a fall upon the anterior portion of the vertex. In the 
latter case the patient died in a few hours, the point that received the 
blow was recognized by the contusion, there was no fracture under it 
and no fissure connecting it with the fracture of the occipital. 

The structure and form of the skull have a marked influence upon the 

1 Etudes experimentales et cliniques sur les traumatismes cerebraux, vol. i. 
Paris, 1878. 

2 Diet. Encyclopedique des Sciences Medicales, art. Crane, p. 598. 



232 FRACTURES OF THE SKULL. 

character and extent of a fracture. In accordance with its variations in 
thickness and with the relations of some of its^parts to other bones some 
portions are more easily broken than others, and lines of fracture begin- 
ning at given points on the vault and extending to the base usually follow 
corresponding lines quite closely. The bone itself is composed of an 
outer and inner table separated by the softer and vascular diploe and 
differing in thickness and brittleness, the inner table being the thinner 
and more brittle. At the lower portion of the frontal bone are found 
the frontal sinuses, irregular cavities of variable size which appear dur- 
ing childhood and increase in size through adult life. They are situated 
between the two tables of the bone, and sometimes extend as high as to the 
frontal eminences and outwards over almost the whole of the orbit. Their 
importance in connection with fractures lies in the separation between 
the two tables by which a fracture of the outer without injury to the 
inner one is rendered easy. The thickest portions of the vault are at 
the base of the frontal bone, the mastoid region, and the occipital tuber- 
osity ; the thinnest at the squamous portion of the temporal and the in- 
ferior fossae of the occipital. Fractures of the vault are produced by 
direct violence ; fractures of the base by the extension of fissures from 
the vault, by the direct impact of the vertebral column, by force trans- 
mitted through the bones of the face, and occasionally by direct violence 
as in gunshot wounds or in blows with a pointed weapon traversing the 
orbit, nostril, or mouth. 

Pathological Anatomy. — This division into fractures of the vault, of 
the base, and of both is practically of great importance, since they dif- 
fer materially in their gravity, and the former alone offer an opportunity 
for direct surgical interference. 

Fractures of the Vault. — With few and rare exceptions, the possibil- 
ity of which has been admitted, fractures of the vault of the skull are 
produced only by direct violence, the fracture taking place at the point 
where the blow is received, and consisting either of a simple fissure or 
of comminution, and either with or without accompanying depression. 
A fissure is usually of considerable length, and may involve more than 
one bone, crossing a suture. Its sides are usually in contact, but may 
be separated by a slight interval if the fissure is long. Comminution is 
the result, usually, of a blow with a blunt instrument delivered with 
much violence, and is seldom accompanied by fissures extending to any 
considerable distance. When such a fracture is extensive the affected 
area commonly presents an irregular, funnel-shaped depression, the sides 
of which are formed by the fragments which remain in contact along the 
periphery with the undepressed portion and slope inwards to the centre 
(fig. 125), which lies at a distance below its normal level, varying from 
a few lines to an inch or more ; or the fragments may be driven bodily 
inwards and entirely separated at the borders from the solid portion, or 
the depressed portion may consist of two principal pieces sloping inwards 
to a central line of greatest depression (fig. 126), one of them, perhaps, 
overriding the other. The inner table is always more extensively frac- 
tured than the outer, except when the fracture is produced from within 
outwards, as by a bullet, in which case the outer table is the one most 
injured (fig. 127). This peculiarity has been attributed to the greater 



FRACTURES OF THE SKULL, 



283 



brittleness of the inner table, but it is due to mechanical causes, and is 
similar to what is seen after fracture of other substances. The dura 
mater is usually torn, but rarely to an extent at all comparable with that 
of the aggregated lines of fracture. 



Fii?. 126. 



Fig. 125. 



Fig. 127. 

iiiifi 





Compound depressed fractures of the skull. 




Fracture of the skull from within 



In exceptional cases the bone, or at least its outer table, is raised above 
its normal level instead of being depressed. Mr. Hewett 1 says two such 
specimens are preserved in the museum of St. George's Hospital ; in 
each a fragment involving the entire thickness of the bone is bent out- 
ward or raised up like the lid of a box, remaining attached to the skull 
along the border which forms the angle. The injury was caused in one 
case by a falling chisel, and in the other by a fall upon an iron railing, 
one of the spikes of which penetrated the skull. A similar case came 
under my observation at Bellevue Hospital ; the patient was struck upon 
the back of the head with a chisel, one corner of which traversed the 
bone, splintering the inner table, and turning up the outer table along 
the edge of the incision. The mechanism is readily understood: after 
the instrument has penetrated the bone its direction is slightly changed, 
and it acts as a lever, prying out the bone on one side instead of forcing 
it in on the other. 

Permanent traumatic depression of the bone without fracture in the 
adult is unknown and inconceivable. It has been shown by experiment 
that the elasticity of the skull is such that a point upon its surface can 
be depressed one-third of an inch Avithout fracture, but the elasticity 
which permits this prevents the depression from persisting after the re- 
moval of the force which produced it. It is possible, perhaps, in the 
softer and more pliable bones of the infant, but even there it is doubtless 
associated with partial rupture of the tissue. 

The term incomplete is applied to fractures involving only one of the 
tables. They are of rare occurrence, but unquestionable examples of 
each variety have been recorded, and cases of extensive splintering of 
the inner table, with only slight injury of the outer table, are not un- 
common. Fracture of the outer table alone may easily occur at the 



1 Holmes's System of Surg., Am. ed., vol. i. p. 618. 



234 FRACTURES OF THE SKULL. 

frontal sinuses, but is rarely met with elsewhere, although it is possible 
wherever the diploe is thick and soft. I observed a case at the Presby- 
terian Hospital in 1881 ; the patient, a man twenty-one years old, had 
fallen from a considerable height, striking upon his head. The bone, 
which was freely exposed through two large scalp wounds at the vertex, 
presented two long fissures, one parallel to and half an inch to the left 
of the sagittal suture, the other posterior to and nearly at right angles 
to the former, along the middle of the left parietal bone. I applied the 
trephine at the centre of each fissure, removing only the outer table in 
the second one, and enlarging the opening with bone-pliers along the fis- 
sure until it measured about an inch in length ; the exposed inner table 
was carefully examined and showed no trace of a fissure. The patient 
made a rapid recovery. 

Fractures of the inner table alone are rare, but have been demon- 
strated both by operation and by autopsical examination. The greater 
brittleness of the inner table seems to be entirely foreign to this limita- 
tion of the injury, the cause of which lies solely in the direction of the 
fracturing force. Legouest and Servier refer to a specimen preserved 
in the museum of Guy's Hospital, which shows a fracture of the exter- 
nal table alone caused by a force acting from within the skull, and is, 
in their judgment, a conclusive proof of the correctness of this opinion. 
Additional arguments in its favor and in opposition to the other view, which 
was formerly held very generally, are furnished, as was first shown by 
Mr. Teevan, by the study of the mechanism of fracture of any homo- 
geneous tissue, and by observation of the manner in which a thin plate 
of ice yields under a slowly acting fracturing force. 

Mr. Hewett says that if a fracture of the vault is accompanied by a 
wound of the integument the fracture is much more frequently limited 
strictly to the seat of the blow than in cases of simple fracture. In 
twenty cases of compound fracture this limitation existed eight times, 
while in fifty-six cases of simple fracture it existed only once. 

Fractures of the Base. — The base of the skull differs from the vault by 
the irregularity of its form, the lack of homogeneousness in its structure, 
the great variations in its thickness, and the presence of many foramina. 
Yiewed from within, it presents on each side three fossae at different 
levels, the highest in front, the anterior, middle, and posterior. Of these, 
the middle one is formed mainly by the temporal bone, and is the one 
most frequently fractured, apparently because of its position in the line 
in which blows are most frequently received. The inferior borders of 
the parietal bones are bevelled on the outer side and fit within the tem- 
porals, so that a downward force exerted upon the parietals at or near 
the sagittal suture and tending to spread them outwards is counteracted 
by the temporals which act as buttresses or as chords to the arc. In 
addition to this strain the temporals are subjected also to the crushing 
one produced by the action of the blow upon the vertex and the resist- 
ance offered by the vertebral column, between which two points they are 
interposed. 

In general terms it may be said the provision against fracture of the 
base by indirect violence is made by thick ridges radiating from the 
occipital condyles, while the intermediate portions, being thus relieved 



FRACTURES OF THE SKULL. 



235 



from the necessity of supporting the strain, are left comparatively thin 
and weak. This arrangement is analogous to that found in other parts 
of the skeleton, and is in accordance with the general principle observed 
throughout of combining the maximum of strength with the minimum of 
weight. While thus protecting the brain from those forms of violence 
to which it is most frequently exposed, this arrangement, however, leaves 
it comparatively unprotected against others to which it is occasionally, 
but much more rarely subjected, that is, against those which tend to 
produce direct fracture. 

Fractures of the base may be direct or indirect. Direct fractures 
are rare, and usually the result of gunshot wounds, but there are not a 
few recorded cases of fracture produced by comparatively slight direct 
pressure upon the thin portions of the base, such as the roof of the orbit, 
the horizontal plate of the ethmoid bone, or the sphenoid, exerted by such 
things as a cane, a foil, a tobacco pipe thrust into the orbit or the nostril. 

The orbit is the most frequent channel through which this injury is 
received, and the cases are remarkable for the slight degree of violence 
which was sufficient to produce the fracture and for the apparent absence 
or the unimportant character of the external wound, in one case only an 
apparently slight scratch upon the eyelid, in another a wound of the con- 
junctiva undiscovered during life, the weapon having passed between the 
lids. In a case reported by Pamard 1 the point of a foil passed between 
the eye and the inner wall of the orbit, broke the plate of the ethmoid, en- 
tered the cavity of the cranium by the inner wall of the sphenoidal fissure, 
and fractured the posterior clinoid process. In another case a testy old 
gentleman, irritated by some one behind him, made a backward thrust 
with an umbrella and drove it through the orbit of his tormentor into the 
brain ; in another, 2 a soldier fencing with a comrade with canes received 
a thrust in his left nostril. He died a few days afterwards with cerebral 
symptoms, and at the autopsy the ferrule was found lying beside the 
sella turcica, the body of the sphenoid having been perforated by the 
cane, and the posterior clinoid pro- 
cess broken off. A similar case Fig. 128. 
(fig. 128) is reported in the first 
volume, page 337, Surgical History 
of the War of the Rebellion. 

Direct fracture of the basilar pro- 
cess has been caused by the dis- 
charge of a pistol into the mouth 
with suicidal intent ; and, finally, 
may be mentioned Harlow's unique 
and very remarkable case reported 
by Bigelow 3 of a tamping-iron 3 J 
feet long, 1J inches in diameter, 
and weighing 13 \ pounds which was 
driven by the premature explosion of a blast directly through a man's 
skull, entering the cheek by the angle of the lower jaw, and passing 




Fracture of the clinoid process by a sword- 
thrust. (U. S. Surg. Hist j 



3 Gazette HeMomadaire, 1865, p. 455. 

2 Dublin Medical Journal, 1851, vol. i. p. 347. 

3 Am. Journal Med. Sciences, July, 1850. 



236 



FRACTURES OF THE SKULL. 



entirely through and out at the centre of the frontal bone near the 
sagittal suture. The patient recovered without paralysis or intellectual 
trouble, but with the loss of sight in the eye of the injured side. 

Fracture of the squamous portion of the temporal bone has also been 
produced occasionally by a blow upon the chin driving the condyle of 
the lower jaw through into the cavity of the skull, and Mr. Jordan 
Lloyd 1 reports two cases of fracture of the external auditory process 
(on both sides in one case) by violence received upon the chin. The 
diagnosis was made by bleeding from the ear and by recognition of an 
irregularity in the wall of the canal at the part corresponding to the 
condyle of the jaw. Neither the cavity of the cranium nor the temporo- 
maxillary joint appeared to have been opened. This variety is classed 
by some among the indirect fractures, but although, strictly speaking, it 
comes under the definition of that term, it is certainly identical in its 
mechanism with the direct fractures above described. 

The same remark and comment may be made concerning those very 
rare fractures limited to the neighborhood of the foramen magnum and 
produced by a fall upon the head, the momentum of the body supplying 
the force which is transmitted directly to the occipital condyles by the 
atlas (fig. 180). Dupla^ 2 quotes from Chauvel one case of death fol- 



Fiff. 129. 



Fig. 130. 




Perforation of the skull by the condyle 
of the jaw. 



Fracture of the base by a fall upon the vertex. 



lowing a fall upon the head, in which the autopsy disclosed an elliptical 
fracture surrounding the foramen magnum and circumscribing the centre 
of the base of the skull which had manifestly been driven in. The rest 
of the skull was intact. The same surgeon produced experimentally an 
analogous double fracture occupying the occipital bone alone and extend- 
ing in two lines three and five centimetres long from the posterior foramina 
lacera into the inferior occipital fossae. The cadaver was that of a man 
63 years old with complete bony fusion of the first six cervical vertebrae. 



1 British Med. Journal, 1882, vol. i. p. 190. 

2 Pathologie exteme, vol. iii. p. 467. 



FRACTURES OF THE SKULL. 



237 



Fig. 131. 




Fracture of the base by a blow on the nose. (Bryant.) 



And Sir Charles Bell 1 reports the case of a young man brought to the 
Middlesex Hospital after a fall upon the head ; he presented no important 
symptoms, and was soon discharged. As he left the hospital he fell dead, 
and the autopsy showed fracture of the borders of the occipital foramen. 
It was thought that the fragments had suddenly become displaced and 
had compressed the medulla. 

Other indirect fractures have been produced by falls or blows upon 
the face, the ethmoid being driven in by a blow upon the nose (fig. lal) 
and the orbital plate of the 
frontal by a blow upon the 
anterior portion of this bone. 
A case which is almost unique 
is mentioned by Sappey ; 2 
transverse fracture of the body 
of the sphenoid produced by a 
fall from a wagon. The pa- 
tient survived eight months, 
death being due to an arterio- 
venous aneurism originating in 
a rupture of the carotid artery 
within the cavernous sinus at 
the time of the accident. Legouest and Servier state that a somewhat 
similar fracture was produced experimentally by Perrin, and that a speci- 
men of a third is now in the Musee Dupuytren. 

Felizet 3 asserts that in fractures of the base the region of the basilar 
process has remained uninjured between the foramen magnum and the 
sphenoid. 

The great majority of fractures of the base of the skull are, however, 
produced by the extension of fractures originating in the vault, and for 
the correct appreciation of this origin we are mainly indebted to the 
labors of Dr. Aran, 4 who made a thorough experimental and clinical 
study of the subject. His experiments were made by letting cadavers 
fall from a height or by striking the skull with a large heavy hammer, 
and he summarized his results in the three following sentences : 1st. In 
no experiment was a fracture of the base produced without fracture at 
the point that received the blow ; 2d. Fractures of the vault usually 
radiate to the base, and are not arrested by the sutures ; 3d. They take 
the shortest route to the base, following the' curves of smallest radius. 

Fractures of this kind show a fissure at the point struck, usually a 
slight one, which enlarges towards the base and may extend in various 
directions, but, as a rule, follow certain definite lines determined by the 
region which receives the blow. Thus, a blow upon the front of the vault 
causes fracture of the base in the anterior fossa ; a blow upon the parieto- 
temporal region causes fracture of the middle fossa, and one upon the 
occipital bone produces lines of fracture extending towards the foramen 
magnum. Prescott Hewett 5 found these statements fully verified by ex- 



1 Surgical Observations, London, 1816. 

2 Anatomie descriptive, 2d ed., vol. i. p. 191. 

3 Recherclies sur les fractures du Crane, Paris, 1873. 

4 Archives Gen. de Meclecine, 1844, 4th ser., vol. vi. p. 

5 Holmes's System of Surgery, Am. ed., vol. i. p. (J27. 



180. 



238 



FRACTURES OF THE SKULL, 



animation of the cases of fracture of the base of the skull admitted into 
St. George's Hospital during a period of ten years. He divided the 
skull into three zones or segments. " An anterior zone formed by the 
frontal, the upper part of the ethmoid, and the fronto-sphenoid ; a middle 
zone, by the parietals, the squamous and the anterior surface of the 
petrous portion of the temporals, with the greater part of the basi-sphe- 
noid ; and a posterior zone, including the occipital, the mastoid, and the 
posterior surface of the petrous portions of the temporals, with a small 
part of the body of the sphenoid." In the less severe cases the line of 
fracture was strictly limited to one of these zones ; of 25 cases it was 
limited to the anterior zone in 5, to the middle zone in 14, and to the 
posterior zone in 6. In the more severe cases it spreads into two or 
even into all three zones ; out of 29 such cases the middle and anterior 
zones were involved in 14, the middle and posterior in 15. In 10 cases 
all three zones were implicated. This analysis shows the great fre- 
quency with which the middle fossa is involved, for of the total of 64 
cases it was broken in 53. Mr. Hewett adds that in the severer injuries 
there may be in addition small circumscribed fractures having no connec- 
tion with the main line of fracture. Thus, the roof of the orbit or the 
posterior clinoid processes may be broken independently. 

Duplay calls attention to the fact that the fracture is sometimes 
parallel, sometimes perpendicular, and sometimes oblique to the axis 

of the petrous portion of the 
temporal bone. The parallel 
fractures (fig. 132) pass in 
front, or at the level, of the 
external auditory foramen and 
end at the foramen lacerum 
anterius, dividing the petrous 
portion into two unequal parts 
of which the smaller, the ante- 
rior one, contains only a por- 
tion of the external auditory 
canal and of the middle ear. 
The perpendicular fractures 
are the most rare, and pass 
just outside of the internal 
auditory foramen, involving 
both the vestibulum and the 
labyrinth. The oblique frac- 
tures, which are much rarer 
than the parallel but more 
common than the perpendicu- 
lar ones, are situated near the 
base of the petrous portion, 
run downwards and inwards 
parallel to the tympanum, and divide the middle ear. Duplay claims 
that the parallel fractures result almost invariably from a blow upon 
the temporal region, the others from a blow upon the occiput. 

Finally may be mentioned those extensive fractures due to extreme 




A- 



Fracture parallel to the axis of the temporal bon 
(Follin and Duplay.) 



FRACTURES OF THE SKULL. 239 

violence in which all or nearly all the bones are shattered, the sutures 
separated, and the fragments displaced and movable. 

It occasionally happens in fractures both of the vault and base, that a 
venous sinus may be injured, and if the fracture is a compound one the 
injury may be followed by severe hemorrhage, which, however, is rarely 
fatal. 

The important practical pathological point in the great majority of all 
fractures of the skull is the degree and character of the associated in- 
jury to the brain and its coverings, and in this must be included not only 
the immediate lesions produced at the moment the injury is received, 
but also the more remote consequences following a permanent change in 
the inner surface of the skull by fragmentation or depression, or by over- 
growth of callus. 

Symptoms and Diagnosis. — The symptoms following an accident 
which has caused a fracture of the skull vary greatly with the part in- 
volved, and the most prominent ones are often those due to the associated 
lesions of the brain and meninges, the detailed consideration of which 
does not lie within the scope of this subject. The symptoms of the 
fractures may be best presented by following the division adopted in the 
preceding paragraphs, and grouping them as those of fractures of the 
vault and fractures of the base. 

1. Fractures of the Vault. — The positive physical signs of fracture 
are depression of the surface of the bone, which may be recognized 
through the integuments when the fracture is simple, and the existence 
of a fissure, comminution, or depression recognizable by the eye or finger 
when the fracture is compound. In the case of a simple fracture the 
diagnosis is often difficult and sometimes impossible, for not only is a 
fissure unrecognizable by the touch, but even a moderate depression may 
escape detection, especially when covered by thick muscles, as in the 
temporal region, or leave the surgeon in doubt because of the difficulty 
of distinguishing between it and an inflammatory swelling, or an extrava- 
sation of blood under the scalp which often gives to the finger the sensa- 
tion of a soft, depressible centre with a firm, hard, circular border. Or 
a congenital depression or senile thinning of the bone may be mistaken 
for the result of a recent traumatism. Duplay cites the case of a man 
who had been rendered unconscious by a fail from the third story of a 
house ; the surgeon found a broad deep depression of the skull over 
which the skin had not been bruised, and prepared to cut down upon it, 
but fortunately the patient recovered consciousness in time to escape the 
exploration by informing him that the depression was not the conse- 
quence of the fall, but had existed from childhood. Similar cases have 
been reported by others. 

When, on the other hand, the bone has been exposed, there is no 
difficulty in recognizing a fracture, or even a fissure in the wound, and 
no objection to enlarging the wound, and even scraping up the perios- 
teum if there is reason to suspect the existence of fracture in the imme- 
diate neighborhood. Error in such a case has arisen by mistaking a 
suture for a linear fracture, but it is one which should be readily avoided 
if the possibility is borne in mind, even if the suture deviates from its 
normal position or is that of a Wormian bone. 



240 FRACTURES OF THE SKULL. 

A very positive sign of fracture is the escape of brain tissue through 
the wound, or of the cerebral liquid through .the wound or under the 
unbroken skin. Mr. Hewett mentions a case in which the inspissated 
secretion of a frontal sinus was mistaken for brain substance. 

Fracture of the inner table alone may be suspected from the character 
of the violence, its existence being considered more probable when the - 
involved area is limited in extent, as in punctured wounds or blows with 
a pointed object such as a nail or spike, or from the later symptoms of 
intra-cranial suppuration, but the diagnosis can never be made positively. 
Its symptoms, physical and rational, are solely those of traumatic menin- 
gitis or cerebritis, and are, therefore, not to- be distinguished from those 
following traumatic extravasation of blood upon the surface of the brain 
without fracture. 

The presence of a fissure upon the surface is not a proof that both 
tables are broken, although it makes it extremely probable, and an inter- 
mittent flow of venous blood from it corresponding in its intermittences 
with the respiratory acts, that is, increasing during expiration, and 
diminishing or ceasing during inspiration, is not a proof that the blood 
comes either from the meningeal vessels or a venous sinus, for when it 
comes only from the diploe near a sinus it may present this character, 
as I observed in the case above mentioned of fracture of the external 
table alone. 

The rational signs are, for the reason already stated, of but little value 
in the diagnosis when the physical signs are in default. The probability 
of a fracture may be strengthened by the character of the violence which 
caused the injury, and, in exceptional cases, by a sign mentioned by 
some authors, a sound like that of a cracked pot heard at the moment 
of the accident by persons standing near the patient. Duplay says this 
sound is often heard in experimenting upon the cadaver, and always 
coincides with the production of a fracture. The presence of a localized 
pain in the head, indicated when the patient is unconscious by repeated 
movements of the hand towards the affected point, is mentioned as a 
probable sign by some writers, but certainly is not sufficient to establish 
the diagnosis. (Edema of the scalp when there is no open wound, and 
persistence of suppuration when there is one, have been long regarded 
as probable signs, but are too indefinite to be at all trustworthy. 

Haward 1 reported a symptom which is probably very exceptional, but 
which, if it occurs and is fairly recognized, is pathognomonic ; the ap- 
pearance under the scalp of a translucent, pulsating swelling due to the 
escape of the cerebro-spinal liquid. In Haward' s case the patient was 
a child 19 months old ; the tumor appeared over the right frontal bone 
after a fall upon the head, increased for ten weeks, and ruptured spon- 
taneously through the conjunctiva eight days after eight ounces of 
liquid had been removed by tapping. A large quantity of liquid escaped 
through the rupture, and it continued to flow during the three days the 
child survived. The autopsy, which was restricted to the seat of the 
fracture, showed a depression of the right frontal bone and a fracture ot 

3 Lancet, July 17, 1869, p. 79. 



FRACTURES OF THE SKULL. 211 

the arch of the orbit through which the handle of a scalpel could be 
easily passed into the brain. 

Mr. Hewett 1 gives eight additional cases of the escape of a clear 
serous liquid after compound fracture of the vault and two after tre- 
phining for epilepsy, the discharge beginning in some immediately after 
the injury, in others not until after the lapse of several days. Of the 11 
cases 8 recovered. In some of the cases the liquid came evidently from 
the lateral ventricle, either through a wound of the overlying substance 
of the brain or by distension and rupture, in others from the subarach- 
noid space. The discharge does not seem to affect the prognosis unfavor- 
ably, except so far as it may be due to associated injury to the brain. 

2. Fractures of the Base. — It is only in very rare and exceptional 
cases, some compound fractures of the more accessible portions, that 
fractures of the base present positive physical signs that can be recog- 
nized by the eye or finger. The symptoms that must ordinarily be de- 
pended upon for making the diagnosis, if we except the probabilities 
arising from the nature of the injury and the associated cerebral distur- 
bances, are the escape of the contents of the cranium, blood, cerebro- 
spinal liquid, or brain substance, through the natural openings or a 
wound, and paralysis of one or more of the cranial nerves. 

Bleeding from the mouth, nose, or ears follows certain fractures of 
the anterior and middle fossae in which a communication has been estab- 
lished between an intra-cranial bloodvessel, usually a venous sinus, and 
the cavity of one of these organs. In many fractures, however, even 
in extensive ones, such a communication is not established, and then the 
symptom is absent. 

"Bleeding from the ears in severe injuries of the head," says Mr. 
Hewett, "has for many years past been held, and deservedly too, as 
one of the most valuable diagnostic signs of fractured base. But the 
bleeding, to be of any real value as a means of diagnosis, must be of a 
serious nature, and, above all, it must continue for some time. With 
such a bleeding it may be safely diagnosed that there is a fracture of 
the base running through the petrous bone and opening up a communi- 
cation between the cavity of the tympanum and some of the numerous 
and large vascular channels which surround this bone, or with an extra- 
vasation of blood within the cranium itself." He found that out of 32 
cases of fracture of the base implicating the petrous portion of the tem- 
poral bone the bleeding from the ear was profuse and continuous in 15 ; 
in 12 of the remaining cases the line of fracture did not extend into the 
tympanum, and in 5 the tympanum was fractured but the membrana 
tympani was not ruptured. In more than half the cases, therefore, this 
sign was absent, but when present its diagnostic value was great. 
Nevertheless it is not absolutely pathognomonic, for there are quite a 
number of recorded cases in which an abundant hemorrhage from the 
ear has followed a severe injury to the head which has left the base of 
the skull unbroken. It follows occasionally fracture limited to the mas- 
toid process, and Duplay reports a case in which it was due solely to 
rupture of the membrana tympani. 

1 Loc. cit., p. 634. 
16 



242 FRACTURES OF THE SKULL. 

Hemorrhage from the mouth or nose, or vomited blood, has less diag- 
nostic importance than that from the ears. The blood comes in some 
cases from the nose or mouth after fracture of the petrous bone, making 
its way through the cavity of the tympanum and the Eustachian tube, 
and if the membrana tympani is ruptured it may escape at the same time 
through the ear. Here too the profuseness and continuance of the bleed- 
ing are a more valuable sign than the mere fact of the hemorrhage, for 
the vascularity of the mucous membrane lining these cavities is such 
that bleeding from it readily follows trifling injuries. Of the 32 cases 
of fracture of the base implicating the central bones of this region ana- 
lyzed by Mr. Hewett, bleeding from the nose or mouth, or subsequent 
vomiting of blood occurred in 14 with symptoms giving rise to the belief 
that the fracture involved some of the bones corresponding to the pharynx 
or nose ; and dissection showed that in 4 of them the fracture was con- 
fined to the ethmoid, in 3 to the body of the sphenoid, and in 1 to the 
basilar process. In 5 both the ethmoid and sphenoid were fractured, 
and 1 the basilar process also. 

Extravasations of blood under the unbroken skin, ecchymoses, have a 
similar diagnostic value for the same reasons, when they are found in 
certain locations and are not due to a local contusion of the soft parts. 
Of these the most common and most important in some respects is effu- 
sion into the orbit, due to fracture of the orbital plate of the frontal and 
of the sphenoid with rupture of the ophthalmic artery or of a venous 
sinus. The blood makes its way forward and appears first under the 
ocular conjunctiva, then under that of the lids, and finally, after the lapse 
of some time, under the cutaneous surface of one or both lids. The 
diagnostic value of the symptoms is greatest when the blow has not fallen 
upon the head near the eyes, when the blood makes its appearance at 
the different points in the order just mentioned, and when the ecchymosis 
is of considerable size. Usually the lower lid is affected earlier and to 
a greater extent than the upper one, but Mr. Hewett says he has seen 
two cases in which the ecchymosis was confined to the upper lid. 

Out of 23 cases of fracture of the base involving the orbital plates of 
the frontal bones, collected by Mr. Hewett, the nature of the injury was 
made manifest in 10 by this symptom ; in 8 cases there was no ecchy- 
mosis, either in the lids or under the conjunctiva, and in 5 the effused 
blood appeared in the eyelids alone. 

A possible source of error in making a diagnosis of fracture of the 
base upon this symptom lies in the fact that blood may, although rarely, 
be effused into the lids or under the conjunctiva after fracture of the 
malar or superior maxillary bone. 

A symptom that has its origin in a similar condition is the formation of 
so-called orbital aneurism, which is most common when the carotid artery 
is ruptured within the cavernous sinus, but may also follow rupture of 
the ophthalmic artery. In a few cases a bruit was heard within the 
head immediately, or within a very short time, after the accident, and 
the usual symptoms of protrusion of the eyeball and dilatation of the 
orbital and frontal veins followed in due time. A somewhat similar 
protrusion of the eyeball unaccompanied by a bruit and dilatation of the 
veins has been caused by an effusion of blood into the posterior portion 



FRACTURES OF THE SKULL. 243 

of the orbit. And Mr. Hewett refers to three cases in which a traumatic 
aneurism, apparently not an aneurism by anastomosis, in the back of the 
orbit was caused by fracture of the base. 

Ecchymosis in the pharynx is rarer and of less value in the diagnosis ; 
Dolbeau is mentioned by Duplay as having reported some cases, the effu- 
sion taking place into the retro-pharyngeal cellular tissue and causing 
ecchymosis and difficulty in deglutition. 

Ecchymosis of the mastoid region or of the side of the neck, appear- 
ing some time after the receipt of an injury, especially if the latter has 
taken place upon the opposite side of the head, has some diagnostic 
value, and Mr. Hewett says that sudden puffiness in the occipital region 
with ecchymosis some hours after a severe injury to this portion of the 
head may also be of use in making the diagnosis of fracture of the base. 
The blood comes from the adjoining venous sinuses, and gradually oozes 
through the fracture and makes its way to the surface. 

A watery discliar ge from the ear or nose, similar to that mentioned in 
connection with fractures of the vault, is occasionally observed after frac- 
ture of the base. It occurs more frequently from the ear than from the 
nose, and is then indicative to a certain degree of fracture of the petrous 
portion of the temporal bone. 

A watery discharge from the ear after fracture of the base is said by 
Duplay to have been vaguely indicated for the first time by BeVenger 
de Carpi, and to have been described with more detail in 1728 by Stal- 
partius Van der Weil, who had observed one case and quoted another. 
Mr. Hewett says that O'Halloran published some thirty years later 
another and even more characteristic case, but adds, that the subject, 
although known to at least one other writer, appears to have been lost 
sight of until 1839 when Laugier 1 first pointed out the connection between 
this discharge from the ear and fracture of the petrous portion of the 
temporal bone together with rupture of the membrana tympani. 

Various origins have been ascribed to this discharge, and it has now 
been proved by numerous analyses and dissections that its source is not 
always the same, and that consequently it is not so certain a sign of 
fracture of the base as has been believed and taught in the past. 

(1) Chemical analysis of the liquid in some cases showed that it con- 
tained a large amount of chloride of sodium and but little albumen, thus 
resembling the cerebro-spinal liquid ; and dissections have shown the 
presence of the lesions necessary to permit the escape of this liquid from 
the cranium, that is, fracture of the internal auditory canal extending 
into the tympanum, rupture of the membrana tympani, and laceration of 
the portion of the arachnoid which accompanies the seventh nerve into 
its foramen of exit. On the other hand, it must be admitted, all these 
three lesions have been found in cases in which this symptom was lack- 
ing. .The facts already mentioned of profuse watery discharge after 
fractures of the vault, in which the liquid unquestionably came from the 
sub- arachnoid space or lateral ventricles, lend additional support to the 
theory of this origin, if any is needed. 

(2) Fedi, quoted by Duplay, published a case in which the discharge 

' Comptes Rendus de 1'Academie des Sciences, 1839, p. 240. 



244 FRACTURES OF THE SKULL. 

from the ear lasted about thirty-four hours, and was estimated at nearly 
three ounces, but in which the autopsy showed no lesion except a frac- 
ture of the base of the stapes establishing a communication between the 
labyrinth and the cavity of the tympanum. (The membrana tympani 
must also have been ruptured or destroyed, but this is not mentioned.) 
In this case the liquid must have been the liquor Cotunnii, and its 
amount can be accounted for only on the supposition that the membrane 
lining the labyrinth continued to secrete it as it escaped. 

Mr. Hewett says there are many such cases in which dissection has 
shown that the fracture did not involve the meatus auditorius internus, 
but passed through the internal and middle ear without touching the 
meatus. 

(3) There are cases in which a profuse watery discharge from the 
ear has followed injury to the head, in which there was no fracture in- 
volving the internal or middle ear, and no communication between them. 
Hewett quotes two such cases, one dissected by Mr. Henry Gray and 
himself, and reported in the Transactions of the Pathological Society of 
London, vol. vi. p. 22, the other by Mr. Holmes ; and Duplay quotes a 
third reported by Ferri in the Gazette Hebdomadaire, vol. i. p. 59. 

In Mr. Hewett's case the patient was brought to the hospital, after a 
fall from a ladder about twenty feet high, with bleeding from the left 
ear and a scalp wound on the upper and back part of the head. The 
next day the discharge was pink and flowing at the rate of two ounces 
per hour. This flow continued for two days, then became much less, 
and on the sixth day was scanty and puriform. The patient died on the 
seventh day with diffuse cellular inflammation of the scalp, and brain 
symptoms. The autopsy showed entire absence of fracture or any in- 
jury of the temporal bone, and of communication between the internal 
and middle ear ; but the membrana tympani was ruptured and the lining 
membrane of the tympanum internally congested and covered with a 
muco-purulent secretion. 

In Mr. Holmes's case the patient was admitted with bleeding from the 
ear, which was followed by a copious watery discharge. The autopsy 
showed no fracture of the temporal bone, and no injury in the cavity of 
the tympanum or the internal ear. The lower jaw was broken just below 
the condyle, and the lower fragment had perforated the Avail of the 
external auditory canal. t 

In Ferri's case there was a watery discharge of sixty-three ounces in 
one hundred and six hours. The patient died six years afterwards of 
caries of the temporal bone of the opposite side, and at the autopsy 
there could be found no trace of fracture upon the side from which the 
discharge had taken place, but only a cicatrix of the membrana tympani 
and the signs of past inflammation of the cavity. 

It thus appears that although a profuse watery discharge from the 
ear is much more commonly associated with fracture of the temporal 
bone than with any other injury, yet it is not absolutely pathognomonic 
of that lesion, and its diagnostic value is only that of a probable symp- 
tom. This value is, moreover, affected by the circumstances of the 
appearance and character of the discharge. Thus, if the discharge 
appears promptly after the receipt of the injury, if it is distinctly watery 



FRACTURES OF THE SKULL. 245 

and is preceded by little or no bleeding, if it is abundant, one or two 
drachms in the hour, and if it is modified by change in the position of 
the head, by coughing or sneezing, the diagnosis may be considered 
positive. If, as happens in a second class of cases, an abundant and 
prolonged hemorrhage precedes the watery discharge the diagnosis of 
fracture of the base is still reasonably certain, but it is based, not on the 
watery flow, but on the bleeding, which has its probable origin in frac- 
ture of the petrous portion. There is, however, a third class of cases 
in which the preliminary bleeding is neither abundant nor prolonged, 
and the watery discharge varies in the time of its appearance and in its 
quantity, perhaps appearing soon after the accident, or being profuse for 
a short time ; in these the diagnosis is doubtful, whether based on bleed- 
ing or on the watery discharge. 

Mr. Hewett says that while it has been taught by some surgeons that 
a profuse watery discharge after an injury to the head occurs most com- 
monly in childhood and youth, the cases which have come under his own 
observation have been for the most part more than thirty years of age. 

The symptom has long been considered a very serious, even a fatal, 
one ; but that the case is not hopeless, even when the diagnosis of frac- 
ture of the base is as certain as it can be under the circumstances, is 
proved by the recoveries which have been recorded. One such recovery 
and one probable recovery have come under my own observation ; in 
both cases the discharge w T as watery, profuse, and continuous, with loss 
of hearing in the affected ear; and in each the injury was caused by a 
violent fall. One case recovered entirely, the other passed from obser- 
vation a week after the accident, but he was then doing well, and the 
discharge had ceased. Still, it is to be regretted that a chemical anal- 
ysis of the liquid has not been made in the cases that have recovered, 
in order that the accuracy of the diagnosis might be comfirmed by all 
possible means. 

A similar profuse watery discharge from the nose has been observed, 
but much more rarely than from the ear. It presented the same chemi- 
cal composition as the cerebro-spinal liquid, that is, it contained a large 
quantity of chloride of sodium, and but little or no albumen, and in one 
case, Roberts, 1 the autopsy showed a fracture (pistol-shot) of the sella 
turcica and laceration of the arachnoid and pituitary body. The liquid 
flowed freely when the body was turned upon its face ; and water poured 
upon the seat of the fracture within the skull ran out through the nose. 
It is, therefore, a reasonable assumption that the flow observed during 
life came from the large sub-arachnoid spaces underlying the brain, and 
also, perhaps, from the ventricles through the infundibulum and torn 
pituitary body. In other cases reported by Foucart and Malgaigne 
(quoted by Hewett), the temporal bone was fractured and the discharge 
reached the nose through the middle ear and the Eustachian tube. 

A possible source of error lies in the copious clear secretion which is 
sometimes poured out by the nasal mucous membrane under the influence 
of even a slight irritation. 

1 Archives Gen. de Med. 1845, 4th series, vol. ix. p. 412. 



246 FRACTURES OF THE SKULL. 

The escape of the substance of the brain through the ear or nostrils 
has been observed in a few cases of comminuted fracture, but the diag- 
nosis appears to have been plain without the aid of this symptom. 

Paralysis of one or more cranial nerves is occasionally observed in 
connection with fractures of the base, as the result either of direct injury 
to the nerve in fractures by direct violence, of rupture of the nerve or 
pressure upon it by one of the fragments when the line of fracture 
crosses its course, or of pressure by extravasated blood. The nerves 
most frequently involved are the 7th pair, the optic, and the olfactory ; 
and, according to Mr. Hewett, 1 examples are on record of injury to 
every pair except the 4th, those of the 8th and 9th being the most rare. 
He mentions a case of the latter in which the injury to the nerve was 
caused on the tenth day after the accident, by the displacement of the 
fragments. The patient was doing well, left his bed on that day, and 
walked across the ward. He was seized with rigors and vomiting, be- 
came unconscious, and died of asphyxia forty-eight hours afterwards 
with increasing dysphagia and gasping respiration. The autopsy showed 
no lesion or inflammation of the brain or its membranes ; the line of 
fracture crossed the right foramen lacerum posterius, and the bones there 
were so displaced that the right cerebellar fossa was lower than the left. 

The diagnostic value of the symptom is only accessory, because it may 
be, and frequently is, due to other lesions than fracture, such as injury 
to the brain itself, intra-cranial extravasation of blood, and hemorrhage 
within the sheath of the nerve. Paralysis of the facial nerve, however, 
has more significance than that of any other. 

The progriosis after fracture of the skull depends mainly if not en- 
tirely upon other factors than those which enter into the prognosis after 
fracture of a limb. The prognosis quoad vitam is grave because of the 
lesions of the brain or its envelopes which may be associated with the 
injury or which may arise in the progress of the case. The injury to 
the bone itself is rarely of a character to leave any disability if the 
patient survives, although a depressed fragment or an exuberant callus 
(which is rare) on the inner side may cause epilepsy or loss of mental 
power, especially if the fracture has occurred during youth. MacEwen 2 
has recently given several illustrative cases. Repair takes place as after 
fracture of the flat bones, described in Chapter VI., that is, the reparative 
material is furnished mainly by the periosteum and diploe'. The result 
of this is that the fractures are slow to unite, because the diploe is usually 
scanty, and, as compared with the marrow of the long bones or the 
spongy tissue of others, is hardly to be taken into account. It was 
shown in the Chapter on Repair how slowly the compact bone tissue pre- 
pares itself to repair a fracture, and as, for some reason which does not 
appear clearly, the pericranium and dura mater do not seem to form 
callus readily and abundantly, the labor seems to fall mainly upon the 
bone itself, and the callus is a small one. When a fragment is depressed 
and the periosteum stripped up, new bone is formed by the latter as 
under similar circumstances elsewhere. 

1 Loc. cit., pp. 655 to 659. 2 Lancet, September, 1881. 



FKACTURES OF THE SKULL. 



217 




Kepair by fibrou 



pbining. 



Loss of substance, unless very small, 
is never entirely repaired by bone, but 
the gap is filled partly by new bone and 
partly by fibrous tissue (fig. 133). 

Treatment. — Here again we have to 
distinguish between fractures of the 
vault and fractures of the base. 

Fractures of the Vault. — After Per- 
cival Pott had so improved the construc- 
tion of the trephine as to greatly di- 
minish the chance of wounding the dura 
mater which was associated with the 
use of the older instruments, it was 
held that active interference was called for in the great majority of cases, 
even when symptoms of cerebral injury or inflammation were not present. 
Pott 1 asserted that " perforation is absolutely necessary in seven cases 
out of ten of simple undepressed fracture of the skull," because it was be- 
lieved that intra-cranial inflammation would almost certainly follow even 
a simple fissure of the skull. The trepan preventif, the use of the tre- 
phine simply with the view to prevent intra-cranial inflammation, was in- 
dorsed by the Academie de Chirurgie, and all surgeons guided their 
practice by this theory until the beginning of the present century, when 
a reaction set in and extended so far that the use of the trephine became 
very rare, and w T as thought to be justifiable only after grave cerebral 
symptoms had made their appearance. Most writers upon surgery dur- 
ing the last twenty or thirty years condemn its use unequivocally except 
in compound fractures with depression and with marked and persistent 
cerebral symptoms. It would be easy to multiply citations in support 
of this assertion; the exceptions to this teaching are rare and seldom go 
beyond admitting the possible propriety of elevating depressed bone in 
compound fracture when there are no signs of compression. The influ- 
ence of this teaching is seen in the following quotation from Bryant: 2 
"At Guy's Hospital, trephining and elevation of bone have been per- 
formed in 51 cases during seven years, and of these only 12 recovered. 
At St. Bartholomew's Hospital it was recorded by Callender in 1867 
that the operation had not been performed for six years. At University 
Hospital, Erichsen gives 6 cases of recovery out of 17." I am not 
aware of the existence of any statistics that show the proportion of re- 
coveries in the cases in which the trephine was not used, and indeed this 
class of injuries does not readily allow the question of treatment to be 
decided by tables of percentages. Morgagni's warning, observationes 
perpendendos, non numerandce sunt, needs to be regarded here as much 
as anywhere, and the study of recorded cases shows, I think, that the 
mortality following the use of the trephine, and upon which its restric- 
tion is so largely based, is to be charged not to the operation, but to the 
lesions whose symptoms finally led to it after a delay that had deprived 
it of most of its chances of success. I should hesitate to express upon 



1 Injuries of the Head, p. 130. 

2 Practice of Surgery, 3d Am. ed., p. 185. 



248 FRACTURES OF THE SKULL. 

so important a point an opinion opposed to that of authors whose authority 
is confirmed by so large an experience, if it were supported only by theo- 
retical considerations, but the periodical publications of the last few years 
show that its results when carried into practice have been favorable, and 
I know that it is held and acted upon by many of the profession in New 
York, in whose knowledge and judgment I have the most confidence. 
Moreover, so far as my own observation and experience go, the practice 
of early active interference yields good results, that is, the percentage 
of success is not only very much greater than that furnished by the 
tardy use of the trephine, but is actually high, especially when the 
wound is treated antiseptically. During the last year, 1880-81, thirteen 
compound fractures of the skull have been treated at Bellevue Hospital 
by trephining, and under this term I include the use of the bone-pliers 
to remove a portion of bone so as to elevate or remove the depressed 
portions. One case was a gunshot fracture, the bullet was buried in 
the brain and the patient died in twenty-four hours. In another the 
fracture was overlooked for nearly a fortnight ; then severe brain symp- 
toms set in, the wound was enlarged, a slight depression found, and the 
trephine applied; pus was found between the dura and the bone; the 
patient died soon afterwards, and the autopsy disclosed a circumscribed 
suppurative meningitis. Of the remaining 11 two died, eight recovered, 
and one is still under treatment with hernia cerebri. Seven of these 
eleven presented no brain symptoms beyond stunning, and were operated 
upon immediately after the accident ; they all recovered, and in two of 
them the amount of bone removed was about three square inches, one of 
them being further complicated by a wound of the longitudinal sinus. 
The remaining four cases presented brain symptoms, they were operated 
upon immediately, 2 died, 1 recovered, and the fourth is the one with 
hernia cerebri, just mentioned. Within the same period I have operated 
at the Presbyterian Hospital upon two cases of compound fracture, one 
with extensive depression, the other with double linear fracture ; both 
operations were done within two hours after the accident, and both 
patients recovered without a bad symptom. In contrast to these I may 
mention two cases that have recently come under my observation, one of 
the tardy use of the trephine, the other of non-interference ; both termi- 
nated fatally, the first with suppurative meningitis, the second with ab- 
scess of the brain. Both fractures were compound and small, both 
patients walked to the hospital, and neither presented brain symptoms 
until after a week had passed. Both, I think, might have been saved 
by an early operation. 

The radical difference between the teachings of a century ago and 
those of the present time is not to be explained by any important ad- 
vance in our knowledge, either of surgical science or of the nature of 
this class of injuries. It is mainly a question of clinical experience : 
Does delay give better results than early operative interference ? And if 
surgeons during the last fifty years have practically limited their expe- 
rience to one method of treatment, they are without sufficient means to 
answer the question, for they know only one side of it, and their opin- 
ions must be judged by the aid of such knowledge as can be drawn from 



FRACTURES OF THE SKULL. 249 

the experience of others, and from the study of the nature of the lesions 
and of kindred facts. 

Curiously enough, the practice of the surgeons of the last century 
has been followed up to the present time in the mining districts of Corn- 
wall, where fractures of the skull are common, and immediate trephin- 
ing is the rule ; and the results of this practice have been recently given, 
in general terms, by Mr. Robert Hudson, 1 who bases upon them an ap- 
peal for the earlier and more frequent use of the trephine. Pie quotes 
Mr. Michell to the effect that a week rarely passed while he was a stu- 
dent without one or two operations, and that he had seen three done in 
a single day, all in the physician's office, and the patients afterwards 
walking home. Trephining is so much the rule that the miners expect 
it even in comparatively slight injuries, and it is not the use of the tre- 
phine, but the failure to use it, that requires to be explained to them. 
Mr. Hudson says the first question of the patient's friends is : " Is his 
skull broken ?" And if that is answered affirmatively, the next is : 
" When are you going to bore un ?" 

There is no lack of experience in non-traumatic cases to show that the 
operation of trephining is not in itself a dangerous one if the dura mater 
is not divided, and the experiments of Mr. Leo 2 have shown that we 
may expect the danger to be diminished, if not entirely removed, by the 
use of the antiseptic method. He trephined 26 monkeys and treated 
the wounds antiseptically ; 19 recovered, and of the 7 deaths only 1 
appeared to be due to intracranial inflammation ; 4 died in consequence 
of the extreme cold of the season, 1 from the effects of the chloroform, 
and 1 from a hemorrhage on the sixth day. All that were trephined 
and treated without antiseptic precautions died of purulent meningo- 
encephalitis. 

Chadborn trephined Philip of Nassau twenty-seven times for epilepsy ; 
and in another case the operation was performed fifty-two times upon 
one individual. Trephining for epilepsy, headache, and vertigo is com- 
mon among the barbarous or semi-civilized peoples of Africa and the 
- Pacific, who submit themselves to it coolly, often twice or three times, 
and apparently without fear of fatal results. Among the Kabyles the 
operators have a semi-religious character, and have usually undergone 
the operation themselves; the instruments are considered sacred, and are 
handed down from father to son through many generations. Between 
1850 and 1870 the operation was done quite frequently in Europe and 
the United States for the relief of epilepsy, and the later abandonment 
of the practice, except in cases having a traumatic origin, appears to 
have been the result rather of its failure to cure the disease than of the 
mortality that followed it. 

The reaction against the use of the trephine appears to have been the 
result of two causes : the success of non-interference in some cases, and 
the failure of tardy interference in others. When a case did not pre- 
sent grave brain symptoms at the outset surgeons were encouraged by 
the former to delay ; and when, finally, such symptoms had set in, and 

1 British Medical Journal, July, 1877, vol. ii. p. 75. 

2 Ibid., May 14, 1881. 



250 FRACTURES OF THE SKULL. 

the patient's chances of recovery were diminished by the complications, 
the failure of the operation to relieve them bred a disbelief in its power 
to prevent them, and strengthened the reluctance, which seems to me in 
this connection to be sentimental rather than surgical, 4o add to the ex- 
tent of the existing lesion by operation. The reasoning consists of two 
propositions and a deduction : 1st, some patients recover without opera- 
tion ; 2d, some die after operation ; therefore, it is better not to operate 
until you are sure the patient will die if you do not. The error, in my 
judgment, lies in the failure to take into account more positively the in- 
fluence of the persistence of the primary lesions in producing the later 
symptoms which point to a fatal termination. All agree that the prin- 
cipal danger arises, not from the fracture of the bone, but from inflam- 
mation of the brain and its coverings, and admit that a depressed frag- 
ment of bone, or even a clot, may excite this inflammation. Why then 
should we hesitate to increase the extent of the comparatively indifferent 
lesion of the bone, if the much more important lesion of the brain or the 
meninges can thereby be lessened or averted ? And that it can be thus 
lessened or averted in many cases there is every reason to believe, on 
both clinical and theoretical grounds. In the other cases the primary 
injury of the viscera is so severe that the removal of the fragments will 
not prevent the development of fatal inflammation. The result seems to 
depend largely upon the condition of the dura mater ; if that is untorn 
the chances are in favor of recovery. 

In compound fractures with depression I think the safest practice is to 
remove immediately enough bone by means of the trephine, Hey's saw, 
or bone-pliers, to allow the fragments to be easily elevated or removed, 
and I think, further, that the surgeon should not be timid about removing 
the latter freely. Great caution must be used in dealing with fragments 
that have been driven through the dura mater, in order that the injury 
to the brain and the meninges may not be increased by the manipula- 
tions. Some surgeons even recommend that they should be left until 
the tissues shall have become somewhat consolidated about them by 
inflammation, but I should consider a slight increase of the laceration 
much less of an evil than the additional stimulus given by the presence 
of the fragment to the inflammatory process, which it is so desirable to 
keep within narrow bounds. The edges of the opening on the inner 
surface must be carefully examined and all projecting points removed. 
Good results have been obtained in two cases 1 by suturing the divided 
dura mater with catgut. 

In compound linear fractures, the question of interference may per- 
haps be determined by consideration of the character of the violence 
that caused the injury ; if it were severe enough or sufficiently circum- 
scribed to make splintering of the inner table probable, I should apply 
the trephine and remove at least the outer table so as to explore the 
inner one. This latter can be easily done in some cases, whenever the 
diploe is abundant and soft. The removal of a disk of bone entails no 
serious disability if the patient recovers, and it enables the surgeon to 
discover and properly treat those complications which experience has 

] W. T. Bull, in Archives of Medicine, vol. i. 1879, p. 219. 



FRACTURES OF THE SKULL. 251 

shown to be liable, if not likely, to exist on the under surface, and even 
if those complications do not exist I believe it to be of advantage by 
providing a free escape for the discharges from the dura mater and the 
surface of the fracture itself. The necessity of drainage in other 
wounds is well established, and that it may be absolutely necessary 
after linear fracture of the skull is shown by those cases in which the 
trephine or the autopsy has disclosed a purulent collection between the 
dura and the bone. It must be remembered that the fracture has al- 
ready established a communication between the meninges and the exte- 
rior, that this communication is a dangerous one, and that while the 
trephine increases it, it also removes much of its danger. A free open- 
ing into an inflamed or suppurating cavity is as beneficial as a small one 
is dangerous. 

In punctured fractures all admit the value of the trephine, and even 
those who are most inclined to delay or restrict its use elsewhere do not 
object to its early application in these cases. 

In simple fractures with or without depression the general practice is 
not to interfere unless or until severe brain symptoms indicative of com- 
pression or intra-cranial inflammation appear. The reasons for this are 
of two kinds : the frequent uncertainty of the diagnosis ; and the less 
chance of intra-cranial inflammation so long as the skin remains unbroken. 
It happens, too, not infrequently that the depression is gradually over- 
come by the constantly acting intra-cranial tension, which is estimated 
by different observers to be equal under normal circumstances to from 
eight to twenty-five millimetres of mercury and is susceptible of tempo- 
rary increase. The principal drawback to the expectative method, when 
successful, is the possibility that a source of irritation may remain which 
will lead to later intellectual or nervous disturbances, especially to epi- 
lepsy ; and it is possible that the antiseptic method may prove so efficient 
in removing the dangers incident to exposure of the cavity of the cra- 
nium that surgeons will consider it justifiable in cases of undoubted de- 
pression to cut down upon the fracture immediately with a view to pre- 
vent the possible occurrence of these late accidents, just as they now 
consider it proper to do so after these or the earlier inflammatory ones 
have made their appearance. 

A limited paralysis in a case of suspected fracture is a positive indi- 
cation for the application of the trephine, although its value is much 
greater when the paralysis is primary than when it is secondary, for the 
former indicates an existing, permanent lesion of the brain immediately 
under the seat of fracture, while the latter may be due to meningitis or 
encephalitis at some distance from the fracture. A beautiful example 
of operation followed by recovery in a case of this kind was reported by 
Lucas-Championni&re. 1 The patient was brought to the hospital uncon- 
scious with a scalp wound above and in front of the ear, and soon showed 
paralysis of the arm of the other side. The wound was enlarged and 
carried down to the bone, a fissure found and traced forward about an 
inch to a distinct fracture, the trephine applied, and a splinter pene- 
trating the dura mater removed. The weight of evidence points 

1 La Trepanation guidee par les Localisations cerebrales, Paris, 1878. 



252 FRACTURES OF THE SKULL. 

strongly to the fact that these localized paralyses are always due to lesion 
of the cortex of the brain under the anterior half of the opposite parietal 
bone, in a region, now known as the motor area, lying on either side of 
the fissure of Rolando, and corresponding to a line drawn on the scalp 
from a point in the median line 2J inches behind the crossing of the 
coronal sutures, to another one, in front of and above the ear, found by 
measuring 2-f inches directly backwards from a point on the posterior 
edge of the external angular process of the frontal bone a little below 
the upper margin of the orbit, and then 1|- inches directly upwards. 
This line is called the Rolandic line, and the motor area is in the form 
of a parallelogram an inch wide traversed centrally by it and stopping 
half an inch short of the sagittal suture. The upper third of the area 
is the centre for the lower extremity, the middle third for the upper ex- 
tremity, the lower third for the face, and the centre for articulate speech 
is at its lower anterior angle or a little below and in front of it. 

Convulsions are an indication for trephining, only when they are 
localized and persistent, and especially if they alternate with paralysis of 
the same muscles. 

In operating for the removal of depressed bone the necessary opening 
may be made in the undepressed portion with the trephine or bone pliers, 
or, if there is a projecting point, with Hey's saw. Whichever instru- 
ment is used the utmost care must be taken to avoid injury to the dura 
mater, and the graphic warning of Sir Astley Cooper, although some- 
what overstated perhaps, may be repeated to enforce this injunction. The 
surgeon should remember, he says, that " there is only the thinness of 
paper between eternity and his instrument." And for a similar reason 
I would urge the employment in the dressing of the wound of the anti- 
septic method in the most rigorous manner possible. The wound should 
be washed with the carbolic solution, the head shaved and washed with 
the same, and then completely covered with the gauze. If the wound is 
in such a position that the gauze cannot overlap it widely enough to 
insure its protection, the edge of the dressing on the narrow side should 
be fastened down with bands dipped in collodion or with adhesive plas- 
ter, or the gauze may be discarded and the wound kept covered with 
compresses wet with carbolized oil or even with the w r atery carbolic solu- 
tion. An icebag during the first few days has seemed useful. If the 
edges of the skin wound are not too much bruised they should be brought 
together with sutures, and an opening left for drainage. 

The general treatment consists of perfect rest and quiet, low diet, 
laxatives, and avoidance of stimulants. If the latter are required im- 
mediately after the accident they must be given cautiously, and discon- 
tinued as soon as reaction begins. 

Fractures of the Base. — Operative interference in these cases is rarely 
called for. Mr. Hewett mentions a case in which the roof of the orbit 
was removed through a wound above the eye, and another in which the 
trephine was applied successfully near the foramen magnum. The gene- 
ral treatment is the same as that of fractures of the vault, and some sur- 
geons use calomel freely to check inflammation. 



FRACTURES OF THE VERTEBRA. 253 



CHAPTER XIII. 

FRACTURES OF THE VERTEBRAE. 

Fractures of the vertebrae have this in common with fractures of the 
skull that most of their importance depends upon the associated injury 
of the nerve centres and trunks contained within their canal, but they 
have in addition the importance due to the function of the spine as a 
support for the head and trunk. Upon the integrity of this support 
depend not only the power of locomotion, but also grace of carriage and 
dexterity in the use of the limbs. The importance of the nerve elements 
contained within the spinal canal is second only to that of those lying 
within the cavity of the cranium ; their injury may result promptly in 
death, or in a permanent disability which maybe considered even worse, 
and even their lesser injuries may be followed by consequences in the 
way of limited paralysis which make life a heavy burden. 

The spinal cord, occupying the centre of the vertebral column, is 
efficiently protected against any external violence that is not sufficient 
to break the bones that constitute the latter, or the ligaments and muscles 
that bind those bones together ; and the column itself is constituted in a 
manner that combines elasticity and mobility with the necessary firmness 
and rigidity. The bodies of the vertebrae, increasing in size from above 
downwards in correspondence with the variations in the weight and strain 
which the different ones are called upon to bear, are composed of spongy 
tissue and separated from each other by the elastic inter-vertebral 
cartilages, and prevented from changing their positions by the interlock- 
ing of the articular processes upon the sides. The general form of the 
column is that of a tall narrow cone with a double antero-posterior curve 
which increases its elasticity, and its component parts are strongly bound 
together by ligaments and muscles allowing a range of motion which, 
while small between each pair of vertebrae, is in the aggregate consider- 
able. Mechanically, therefore, the spine is exposed to fracture by direct 
violence, like other bones, and by indirect violence through exaggeration 
or straightening of its normal curves. 

According to the statistics in the tables in Chapter I., fractures of the 
spine are relatively very rare, only 172 cases being found in the 51,938 
fractures treated in the London Hospital during a period of thirty-five 
years. Gurlt collected, however, upwards of 300 cases in which this 
diagnosis was certain and constructed from them the following tables, 
which show T the relative frequency with which the different vertebrae are 
broken and with which they occur at the different ages and in the two 
sexes : — 



254 



FRACTURES OF THE VERTEBRA. 





Fractures. 


Vertebra}. 










Fatal cases. 


Recoveries. 


Totals. » 


1st cervical 


6 





6 


2d 


11 . 


«• 


11 


3d 


12 S 


1 <y 
1 SS 


13 


4th " 


26 | 


2 w 


28 


5th " 


39 £ 


5 *- 


44 


6th " 


44 o 


2 5 


46 


7th " 


26 « 


4 


30 




■ 


— 





Total 


164 


14 


178 




. <*-. r-< 


■ —— 







O^B 








ic 9> o S ~ 






1st dorsal 


o o 2 •— _x *" 


1 


10 


2d 


8 g« S-o S3 


1 


9 


3d 


io ^!°§£ 





10 


4th " 


ii 


. 


11 


5th " 


10 


2 S 


12 


6th " 


11 i 


l s 


12 


7th " 
8th " 
9th " 


7 «■> oj 

8 e "J 


3 m g "C 


8 

8 

11 


10th " 


H £ 03 03 


6 5 £ 


17 


11th " 


19 a 5? 


G S-s 


25 


12th » 


35 g^ 


8 1? 


43 


"lower" 


o £ 3 


8 cj 


8 




oo 


— £-S 







146 O 


38 Si 


184 




cq «2 3 


o . 


i 


1st lumbar 
2d 


'84 | 5 2 
16 S ^3 


11 2 °°| 

7 £ a^ 


45 
23 


3d 


p ° p 
6 ^ - 


9 


4th " 


3 a - 1 = 


2 ^ 


5 


5th " 


M 


^ 







56 


26 


82 


Gross totals 


366 vertebrae 


78 vertebrae 


444 vertebras 




broken in 217 cases. 


broken in 53 cases. 


broken in 270 cases. 



This table shows that, comparing the different regions, fractures of 
the cervical and dorsal vertebrae are about equally frequent, 178 and 
184 respectively, while those of the lumbar vertebrae, 82, are much less 
common ; that the fatal cases of fracture of the cervical vertebrae are, 
however, considerably more numerous, actually and relatively, than 
those of the two other regions ; and, comparing the different vertebrae, 
that the fifth and sixth cervical, the last dorsal and the first lumbar are 
more frequently broken than any of the others ; and that it is common in 
fractures of the cervical and dorsal regions for more than one vertebra 
to be broken at the same time. 

In the following table the cases are arranged according to location, 
age, and sex : — 



FRACTURES OF THE VERTEBRAE. 



255 







Cervical. 


Dorsal. 


Dorsal and 
luujbar. 


Lumbar. 


Totals. 


Age. 


Fatal. Recov 


Fatal. 


Kecov 


Fatal. Eecov 


Fatal. iRecov 


Fatal. 


Recov 




M. 

4 

16 

17 

21 

7 

3 

1 

23 

92 


F. M. 


F, 


M. 

1 
15 
22 

10 
5 
2 

*8 
63 


F. 

i 

; 

7 


M. 

2 
5 

2 
6 
3 

"o 

23 


F. 

i 

i 


M. 

'4 
4 
4 
1 
1 

1 
15 


P. M. 


F. 


M. 

4 
7 
3 
4 
1 
1 

20 


F. 

'i 


M. F. 
iL 

2 .. 

.:; 

2 .. 

.. 1 

3 '.'. 


M. 

9 

42 
46 
39 
14 

7 
1 

"38 


F. 
- 

2 

G 

'4 
2 
2 

1 
1 
1 

19 


M. 

4 

12 
10 

10 

3 

io 



51 


F. 


15 to 19 . 
20 " 29 . 
30 " B9 . 
40 " 4tf . 
fiO " 59 . 
60 " 69 . 
70 " 79 . 
80 " 89 . 
"Adults" 




1 

3 

1 

i 

l 
l 

l 


4 
1 

1 


1 

"i 


1 
1 
3 
2 

'i 


'i 

•• 


Totals 


9 7 


•• 


2 8 


, 113 1 


196 


2 






108 




< 


14 






g 


5 




41 


286 



This table shows the extreme rarity of fractures of the spine in child- 
hood and old age, especially in the former, the youngest case being 
sixteen years old, the oldest eighty-three. Gurlt attributes the rarity in 
childhood to the absence of bony consolidation of the epiphyses, but I 
am more disposed to consider it the result of the greater elasticity of the 
ligaments, which, as is well known, permits a greater freedom of motion 
in most joints during childhood than during adult life. The great 
number of cases occurring between the ages of twenty and fifty years, 
and the comparative infrequency of the injury in women must be attri- 
buted to the greater exposure to the accidents which may cause fracture 
of the spine incident to the occupations of males in the prime of life. 

By a detailed analysis of the cases which furnished these tables Gurlt 
ascertains that the part most frequently fractured is the body of the 
vertebra, that is, in about two-thirds of all cases, or in more than half of 
the fractures of the cervical vertebrae, in about seven-eighths of those of the 
dorsal vertebrae, and in about all of those of the lumbar vertebras. Or, 
in general terms, fractures of the bodies of the vertebrae begin at about 
the middle of the cervical region and increase in frequency downwards. 
Simultaneous fracture of two or more vertebrae is common in the cervical 
and upper dorsal regions, less common in the lower dorsal, and rare in 
the lumbar region. Fracture of one or more of the vertebral processes 
either of the same or of adjoining vertebrae is common. 

Pathology. — The fracture of the body of a vertebra may be complete 
or incomplete ; the line of fracture may extend only partly through it or 
entirely across it, or it may be broken into several fragments, or com- 
pressed, or impacted. The line of fracture, if single, may be vertical, 
horizontal, or oblique in any direction ; the first being found almost ex- 
clusively in the cervical and upper dorsal regions, the two latter and 
multiple fractures occurring everywhere. The transverse and oblique 
fractures lie, as a rule, nearer the upper than the lower border of the 
bone, and may pass from the upper to the anterior surface, leaving the 
posterior and lower surfaces unbroken, and in these cases the upper 
fragment preserves its relations to the overlying vertebra and is displaced 



256 



FRACTURES OF THE VERTEBRA 



with it forwards and downwards, producing a change in the long axis of 
the spine characterized by an angle having its apex directed backward at 
the seat of fracture. This displacement narrows the antero-posterior 
diameter of the spinal canal and lacerates or compresses the spinal cord 



Fig. 134. 





Transverse fracture of vertebra. 



Displacement of the vertebrae causing compression of 
the spinal cord. 



Fig. 3 36. 



within it. If the line of fracture is oblique, and if fracture or dislocation 
of the oblique processes is associated with it, the displacement is inclined 
to the corresponding side either directly or by rotation. 

Compression of the body of a vertebra, similar to that observed in 
other spongy bones, is found either in combination with comminuted 

fracture or alone, and involving one or 
several vertebrae. The conditions of its 
production are not entirely known, but 
one is thought to be an unusual degree 
of softness or porosity of the bone allow- 
ing it to yield under the pressure ex- 
erted by forcible bending forwards of 
the spinal column. When this move- 
ment of forward flexion is carried be- 
yond its normal limits, either the poste- 
rior portions of the vertebrae must sepa- 
rate from each other or the anterior 
portions must approximate by conden- 
sation of the inter-vertebral disks or of 
the bone. When the latter takes place, 
as in the circumstances under considera- 
tion, the concave surfaces of the body 
of the vertebra are flattened, and its an- 
terior surface made shorter than its posterior one, the compression being 
of course more marked the greater the distance from the fulcrum (fig. 




Compression of the last dorsal vertebra. 



FRACTURES OF THE VERTEBRAE 



257 



136). The compression may be so extreme that the intervertebral disks 
above and below the affected vertebra are brought into contact with 
each other in front, the substance of the bone being partly compressed 
and partly forced out upon the sides or behind into the spinal canal 
(figs. 137 and 138), compressing the cord. With this compression may 



Fig. 13' 



Fig. 13S. 





Fracture with compression of the 3d and 4th lumbar vertebra?. 

be associated fracture or fissure of the body, and especially fracture of 
the processes of the same or the adjoining vertebra. The same shortening 
of the anterior portion of the body may be produced by splintering of 
part of the bone or by impaction of one fragment into another lying 
above or below it. This latter condition was found in four of Gurlt's 
cases, three times in the twelfth dorsal and once in the first lumbar 
vertebra. 

Fracture of the vertebral arches, according to Gurlt, is found in 
about half the cases of fracture of the cervical vertebrae, and only in one- 
seventh of those of the dorsal, and one-eighth of those of the lumbar. 
On the other hand, Dr Wyman 1 reported eleven cases of supposed frac- 
ture of the arches of the fourth and fifth lumbar vertebrae between the 
lower articular and the transverse processes, all old and ununited, four 
of the specimens being taken from ancient Indian graves. The nature 
of these supposed fractures is in doubt, and it is thought by some that 
they are merely instances of arrest of development. (See p. 270.) 

Gurlt attributes the frequency of this form of fracture in the cervical 
spine to the comparatively greater breadth and less height of the arch and 
to the absence of that protection which is furnished in the dorsal and 
lumbar regions by the larger and stronger spinous, transverse, and oblique 
processes. In fractures by direct violence, which Gurlt seems to have 
had principally in mind, this explanation would be sufficient, but Wyman's 
cases, if they are to be accepted as fractures, indicate an unsuspected 
frequency in the lumbar region and ' a different mechanism. Wyman 



17 



1 Boston Med. and Surg. Journal, Aug. 12, 1869. 



258 FRACTURES OF THE VERTEBRAE. 

calls attention to the fact that the articular processes of the lumbar 
vertebrae are widely separated from each othet, as compared with those 
of the dorsal vertebrae, and are connected only by a narrow neck, and he 
attributes the fracture to extreme backward flexion or to the shock of a 
fall upon the feet. It seems not improbable that some of the severe 
strains of the lower portion of the back which leave a more or less marked 
permanent weakness or sensitiveness of the part may be fractures of the 
arch without displacement and possibly without union. When the arch 
is broken on each side the intermediate portion bearing the spinous pro- 
cess may be driven into the spinal canal and cause fatal laceration or 
compression of the cord. Gurlt's statistics contain six such cases, affect- 
ing the fifth, sixth, and seventh cervical vertebrae. 

The sjjinous processes are broken most frequently at those points 
where they are longest and thinnest, nearly one-fourth of the cases oc- 
curring in the cervical spine, more than half in the dorsal, and about one- 
eighth in the lumbar; and often several adjoining ones are broken at the 
same time. In the dorsal region this fracture usually accompanies frac- 
ture of the body of one of the vertebrae above or below it. Isolated 
fracture of a spinous process may occur as the result of direct violence, 
or, possibly, of muscular action, and the displacement is either directly 
downwards or to one side. Sir Astley Cooper saw a case in which three 
or four of the processes were broken off by an effort to support a heavy 
wheel. The patient, a boy, passed his head between the spokes and 
took the weight upon his shoulders ; it proved too great and he fell, bent 
double. The muscles were torn upon one side, producing obliquity in the 
line of the spine at the seat of fracture, the fragments being displaced 
to the other side. There was no paralysis, and the patient recovered 
promptly with integrity of functions, but persistence of the deformity. 
Malgaigne saw a case in which the spinous process of the axis was 
broken by the passage of a cart across the shoulders and neck. The 
patient died of associated injuries, and the fracture was verified by a 
post-mortem examination. 

Fracture of the transverse or oblique processes occurs in combination 
with other fractures in about one-sixth of all cases, but is rare except in 
such combination. In the few instances in which it has occurred alone 
it was the result of gunshot injury. As a complication of other fractures 
the proportion of its occurrence for the transverse process is greatest in 
the cervical and next in the lumbar and dorsal regions ; for the oblique 
processes it is greatest in the cervical and smallest in the lumbar. Frac- 
ture of a transverse process of a dorsal vertebra may lead to fracture of 
the rib which articulates with it, and fracture of the transverse process 
of a cervical vertebra may seriously injure the vessels contained in the 
spinal canal. Fracture of an oblique process exposes to dislocation of 
the vertebra with all its accompanying dangers. 

The ligaments which bind the different vertebrae together are torn in 
fracture to an extent which varies with the severity of the injury and 
the degree of the displacement, and the intervertebral disks may be 
torn, displaced, or compressed. In rare cases the injury may be con- 
fined to the ligaments and disks, real dislocation without fracture, 
although the distinction cannot be made during life. I saw at La 



FRACTURES OF THE VERTEBRAE. 



259 



Fis:. 139. 



- 



Charite, in 1874, in the service of Prof. Trelat, a specimen of such a 
dislocation between the sixth and seventh cervical vertebrae produced by 
forced flexion of the neck forwards. The yellow ligament was entirely 
torn off and the inter-vertebral disk crushed, but no bone or process was 
broken. The patient died by asphyxia within twenty-four hours •after 
the accident. The muscles and tendons, too, are unusually torn, especi- 
ally those lying nearest the bones and ligaments ; and extravasations of 
blood form as after other fractures and extend along the cellular inter- 
spaces between the muscles and in front of the spine, sometimes into the 
posterior mediastinum, and sometimes into the retro-peritoneal tissues, 
surrounding the kidneys and the iliacus and psoas muscles. Ecchymoses 
may appear on the face or chin after fracture of the cervical vertebrae, and 
as low even as the loins in other cases. If the displacement is such as to in- 
jure the cord large collections of blood may form within the spinal canal, and 
in some fractures of the cervical vertebrae the vertebral artery is divided. 

The spinal cord, the diameter of which is considerably less than that 
of the canal in which it lies, is suspended within the 
dura mater, which is itself loosely connected with the 
bones and separated from direct contact with them in 
most places by a rich venous plexus. The medullary 
portion of the cord ends at the first or second lumbar 
vertebra, and its lower portion is enveloped by the 
numerous nerve trunks which pass downward to form 
the cauda equina and the lumbar and sacral plexuses. 
The cord is injured directly only when the lumen of 
the canal is considerably encroached upon by the dis- 
placement of a fragment or of a vertebra, but it can 
be compressed by extravasated blood or by inflam- 
matory exudations. Extravasated blood usually lies 
between the dura and the bone behind or on the sides, 
and is furnished by the veins just mentioned. The 
cord itself is seldom the seat of any considerable 
hemorrhage even when it has been badly crushed or 
lacerated. Occasionally the cord is penetrated by a 
sharp fragment, but usually the dura mater is untorn 
and the cord is crushed between the anterior portion 
of one fragment or vertebra, usually the lower, and 
the posterior portion of another, usually the upper. 
This crushing presents all degrees, from a slight flat- 
tening to complete rupture either structural or func- 
tional by disorganization of the tissues. 

Figure 139 represents the lower portion of the 
spinal cord after simple transverse fracture of the first 
lumbar vertebra. The patient died on the nineteenth 
day. * The spinous and left transverse processes en- 
croached upon the cord which was lacerated at the 
lumbar and dorsal junction. The membranes were 
entirely torn across, and " the tubular nerve fila- 
ments have been curiously dissected out by the pus Laceration of the cord, 
in which the cord was bathed." < u \ s ; Med " aud Surs ' 

MlSt.) 




260 FRACTURES OF THE VERTEBRAE. 

Etiology. — Besides those causes, general and local, mentioned in 
Chapter IV., which predispose to fractures m general, there are two 
local ones which lead occasionally to fracture of the spine — aortic aneur- 
ism and ankylosis following spondylitis deformans and due to the 
growth of osteophytes or ossification of the ligaments and intervertebral 
disks. The first acts by causing absorption of the bone, the loss of sub- 
stance sometimes involving almost the entire body of the vertebra and 
opening the spinal canal ; this allows the column to bend forward, and 
brings a strain upon the articular processes which they are not prepared 
to meet and under which they break. The second, ankylosis, favors frac- 
ture, especially when it involves several adjoining vertebrae, by the 
rigidity which it creates, and the powerful fracturing leverage thus 
furnished to movements of flexion even within the normal range. In 
short, it transforms a row of short bones movable upon each other into 
a rigid long bone. 

The immediate causes are muscular action and external violence. The 
former is exceedingly rare ; one case has been already mentioned in 
Chapter IV., in which the neck was broken by the forcible bending of 
the head backward in an effort to save it from striking against the 
ground when the patient was diving and found the water less deep than 
he had supposed. It is doubted by some if such are really cases of 
fracture by muscular action, and it is thought that although the face 
was not bruised, and the patient declared it had not struck the ground, 
yet it might have done so. Schede, 1 however, reported at the Tenth 
Congress of the German Gesellschaft iiir Chirurgie a case which seems 
unquestionable, for the patient's hands struck the ground and protected 
the head. The patient survived three weeks. Schede says three analo- 
gous cases have occurred : in each the fracture was of the fourth or fifth 
cervical vertebra. An undoubted case of fracture by muscular action 
is quoted by Gurlt from Lasalle ; the patient was a lunatic who, in his 
efforts to free himself from a chair, in which he had been bound, bent 
his head forcibly backwards and forwards and produced a dislocation 
between the fifth and sixth cervical vertebrae with fracture of several 
processes. In other cases in which the patients have tried to lift a 
heavy weight by placing the shoulders under it and then, finding them- 
selves unable to support it, have fallen, it is not always easy to dis- 
tinguish between the effects of the muscular effort and those of the fall- 
ing weight. 

Of 286 cases tabulated by Gurlt according to the character of the 
fracturing force, 176 were caused by a fall from a height, and 50 by the 
fall of a heavy body upon the patient. The cases in which the action is 
exerted directly upon the bone that is broken are -relatively few in num- 
ber, and the great majority are fractures by indirect action. To under- 
stand the mode of production of these latter it must be remembered that 
the spinal column is like a many-jointed rod possessing a flexibility 
which varies at different points. This flexibility, which is largely due 
to the elasticity of the inter-vertebral disks, is restricted by the inter- 
locking processes and ligaments, and its variations in extent and direc- 

> Supplement to Ctblatt fur Chirurgie, 1881, No. 20, p. 33. 



FRACTURES OF THE VERTEBRA. 261 

tion are due to the differences in the form and relations of the articular 
processes. The range of motion is greatest in all directions in the cer- 
vical portion and is least in the dorsal portion, especially in the antero- 
posterior direction, while the lumbar portion allows free flexion but 
almost no rotation. This combination of different degrees of flexibility 
seems to account for the greater frequency of fracture at certain points, 
according to a mechanism pointed out by Sir Charles Bell who compared 
the spine to a jointed fishing-rod which breaks, when over-bent, close to 
a rigid joint rather than in the centre of one of its long elastic pieces. 
In like manner the spine breaks most frequently at or near the points 
where a flexible portion adjoins a comparatively rigid one, for example 
at the union of the cervical and dorsal and of the dorsal and lumbar 
portions. These points correspond to the ends of the normal curves of 
the spine rather than to their centres. 

Indirect fracture takes place usually by forced flexion beyond the 
normal limits, whether the force is exerted by a fall upon either end, 
by the action of a heavy body, or by flexion of the trunk ; and it has 
been shown by Philipeaux's experiments upon the cadaver that the 
forced bending forwards of the trunk causes most commonly an oblique 
fracture of the body of the eleventh or twelfth dorsal vertebra, the line 
of fracture running forwards and downwards. In only a few of the 
cases collected by Gurlt was the fracture caused by the simple flexion of 
the trunk ; in most the mechanism was more complicated, by the fall 
either of the body from a height or of a weight upon it, or by an una- 
vailing effort to lift or resist a weight, the fracture taking place in the 
latter case at some distance from the point where the weight rested or 
struck ; and in one unique case the atlas was broken in rough play, the 
patient being seized by the brim of his hat, and his head forcibly bent 
from one side to the other while he was forced down upon a seat. 

The fractures by direct violence are few, only fourteen in Gurlt's 
collection ; and the force was exerted in almost every case upon the 
posterior portion of the column, fracturing first the spinous processes or 
the arches, and then in some cases the bodies of the vertebrae, or caus- 
ing a dislocation. In most of these cases the violence was a blow, and 
in only one was the fracture compound, a fracture of the neck caused 
by two cows walking over the patient as he lay in a ditch. 

Symptoms and Diagnosis. — The symptoms of fracture of the spine 
vary with the position and the portion of the vertebra involved, and 
therefore need a separate and detailed consideration in connection with 
the different groups of fractures. But there are certain general symp- 
toms common to most w T hich may first be mentioned. After the first 
shock of the injury, which usually passes off without permanent impair- 
ment of the intelligence, the patient complains of a localized pain at the 
seat of fracture increased by manipulation or movements. There is 
usually a recognizable deformity consisting of a change in the direction 
of the spine, a more or less marked angular projection backwards with 
or without swelling of the surrounding soft parts ; crepitation can some- 
times be made out by the surgeon, but more commonly it is appreciable, 
if at all, by the patient himself when his body is moved. The most 



262 FRACTURES OF THE VERTEBRJS. 

important and constant symptom is paralysis, motor and sensory, more 
or less complete, of the limbs and the portion of the body lying below 
the fracture. If complete its upper limit is usually sharply defined by 
a line crossing the trunk and corresponding to the adjoining limits of the 
regions supplied by the nerves that leave the column immediately above 
and below the point at which the cord has been injured. The conse- 
quences of this paralysis, if it involves the abdominal muscles, bladder, 
and rectum, are retention of urine and feces, followed by incontinence 
of one or both, by alkaline fermentation of the former, and cystitis. 
Respiratory difficulties, sometimes severe enough to cause death, appear 
when the fracture involves the upper portion of the spine, the result of 
the paralysis either of the abdominal muscles or of the diaphragm. 
There is also great tendency to sloughing at all points of pressure 
within the paralyzed region, especially over the sacrum, trochanters, 
the tuberosities of the ischii, and along the back. The sloughs appear 
promptly, sometimes within two or three days, are usually symmetrical, 
and often hasten death even if they are not its immediate cause. 

The paralysis is usually so complete that even reflex contractions can- 
not be excited, and the muscles quickly lose their contractility under 
electrical stimulus. If the paralysis of sensation is incomplete, so that 
pinching can be only slightly felt, the ability to distinguish between heat 
and cold may exist unaltered; and occasionally there is hyperesthesia 
of the surface so marked that the slightest touch causes pain, and in a 
few cases sharp shooting pains have been observed in the course of the 
main nerve trunks of the legs, excited by slight movements of the trunk 
or of the limbs, but not by direct pressure upon the spine. This ex- 
treme sensibility has been attributed to the irritation of splinters press- 
ing upon the spinal cord, but the opinion lacks anatomical proof. It 
is also a common symptom of commencing improvement, appearing with 
the return of reflex irritability and muscular twitchings or spasms. 

Tonic or clonic muscular spasms are observed in the anus, and more 
rarely in the legs and body, and may be excited by a great variety of 
causes, such as irritation of the surface by a touch or a current of cold 
air, or change of position of the limbs or of the body. 

The temperature of the paralyzed portions shows changes which are 
not always the same, being sometimes increased, sometimes diminished, 
and sometimes unaltered. Marked elevation of the temperature has 
been observed in experiments upon animals after complete or partial 
division of the spinal cord in its upper portion, and the same has been 
noticed clinically. Gurlt quotes a case from Sir Benjamin Brodie, 
in which, after fracture of the fifth and sixth cervical vertebrae with 
slow diaphragmatic respiration, small pulse, and livid countenance, 
the temperature between the scrotum and thigh rose to 111° Fahr. ; 
the patient died in twenty-two hours. I saw in Prof. Gosselin's wards 
at La Charile in 1875 an example of the same injury, fracture of 
the fifth and sixth cervical vertebrae caused by a fall while turn- 
ing a somersault, with forced flexion of the head upon the chest, in 
which death by asphyxia followed in twenty-four hours, the temperature 
rising to 106°. A symptom in this case and in the similar one of Tie- 
lat's above mentioned was the expectoration towards the end of life of a 



FRACTURES OF THE VERTEBRAE. 263 

good deal of blood, and at the autopsies the lungs were found very much 
congested. In Gosselin's case the spinal cord was compressed by the 
displaced vertebra and congested, but not divided. A very remarkable 
case of high temperature following injury of the spine was reported by 
Mr. Teale. 1 The elevation was constant for several months, the maxi- 
mum being 122° Fahr. The patient recovered. 

Persistent and obstinate vomiting has been observed in some cases, 
most frequently after fracture in the lower cervical portion, and at the 
autopsy of one such case the mucous membrane of the stomach showed 
numerous ecchymoses, and there was half-digested blood in the cavity of 
the viscus. In two cases this vomiting, which was accompanied by com- 
plete constipation, became fecal, and remained so until a movement of 
the bowels was obtained. In both cases the fracture was of the cervical 
spine, and the paralysis was complete in the lower limbs and almost com- 
plete in the arms. 

Priapism, more or less complete, was observed, according to Gurlt, in 31 
of 96 cases of fracture of the cervical and two upper dorsal vertebrae, 16 
times in 133 cases ot fracture between the third dorsal and second lumbar 
vertebrae, and never in fracture below the latter. It appears promptly, 
usually on the first or second day, and seldom lasts longer than a fort- 
night. Notwithstanding the insensitiveness of the penis it may be caused 
or increased by the use of the catheter. On the other hand, in one case 
the erect organ became relaxed as soon as the catheter had passed over 
half the length of the urethra. Ejaculations are very exceptional, there 
being only lour instances in Gurlt's collection, all of them in cases of 
fracture of the cervical spine; in one case they were continuous, in 
another they were excited by the introduction of a catheter. 

Fracture of Atlas and Axis. — The intimate relations existing between 
these two bones and the medulla oblongata, and their position above the 
root of the phrenic nerve as well as above those of the other nerves sup- 
plying other muscles which aid in respiration, make their injury especi- 
ally dangerous, and have probably led to the generally received opinion 
that their fracture is, as a rule, immediately fatal. Gurlt's cases show, 
however, that this opinion is not correct, for in the eleven in which the 
nature of the injury was demonstrated by the autopsy, death occurred 
immediately in only two, and in only two others within an hour after the 
injury was received. In the other cases the patients survived for a con- 
siderable length of time, thirteen clays in one, although some of them at 
the last died suddenly, apparently by displacement of the vertebrae due 
to incautious movements. The fractures were all caused by external 
violence, sometimes slight, as a fall from the bed while trying to reach 
down to the floor. 

The parts broken in ten of these eleven cases were : the odontoid pro- 
cess alone once ; the odontoid process and posterior arch of the atlas three 
times; the posterior arches of the atlas and axis three times; the pos- 
terior arch of the axis alone once ; the spinous process of the axis twice. 
In six of the cases there was associated fracture of the cervical or dorsal 
vertebrae, and in no case was the transverse ligament torn. Figure 140, 
taken from a specimen in the museum at Braunschweig, shows a fracture 

1 Lancet, March 6, 1875. 




264 FRACTURES OF THE VERTEBRJ. 

of the superior articular surface of the axis. The patient was twenty-four 

years old, and died in a few hours after falling out of a wagon upon his head. 

Dr. Chas. T. Hunter 1 explains the frequency of fracture of the axis, 

as compared with that of^the atlas, or 
Fi S- 14 °- with rupture of the transverse ligament, 

by the fact that the structure of the 
body of the axis is comparatively spongy, 
and he shows that its weakest point is 
about one centimetre below the neck of 
the process. 

The symptoms of this fracture are so 
variable and so indefinite and have so 
much in common with simple dislocation 
of one bone upon the other, or of the 
atlas upon the skull, that the diagnosis 
is extremely difficult. On the one hand, 
the patient may die instantly; on the 
other, he may survive a longer or shorter 
?racture throng: time > e ither completely paralyzed or 

surfaces of the axis. (Gurit.) presenting no important symptoms, and 

then die suddenly by displacement of 
the fragments or gradually by extension of the symptoms, or in conse- 
quence of other injuries, or, if the diagnosis in some such cases may be 
accepted, may even get well. The symptoms of local pain and stiffness 
of the neck are too indefinite to be of any service, and paralytic symp- 
toms may be entirely absent, as in Gurlt's second case where the patient 
walked for two hours after the accident to reach home and developed no 
paralysis until the following day. Death took place suddenly on the 
eighth day, and the autopsy showed fracture of both arches of the atlas 
and of the odontoid process. 

The symptoms in those of Gurlt's eleven cases which survived long 
enough to present any, or in which any are recorded, were complete 
paralysis of all the parts below the fracture in some, partial paralysis 
in others, only a slight diminution of sensibility in the left arm in one, 
pain in the neck or occiput in six, rigidity of the neck in most, absence 
of recognizable deformity in all, distinct crepitation in one, and falling 
forward of the head upon the breast in one. All of these symptoms — 
pain, rigidity, paralysis, sudden death — may be the result of dislocation 
as well as of fracture ; and as dislocation has in addition no characte- 
ristic, general or local, symptoms which serve to distinguish it the differ- 
ential diagnosis must usually remain in doubt. 

Fractures of the lower five Cervical and first two Dorsal Vertebrae. 
— The special characteristics of fractures of this region are due to the 
inclusion within it of the roots of the phrenic nerve and brachial plexus. 
The former passes out through the intervertebral foramen between the 
third and fourth cervical vertebrae, either coming from the fourth cer- 
vical pair alone, or receiving branches also from the third and fifth 
pairs. The brachial plexus is formed by the four lower cervical and 

1 Holmes's System of Surgery, Am. ed., vol. i. p. 808. 



FRACTURES OF THE VERTEBRAE. 265 

the first dorsal pairs. Consequently, if the fracture is accompanied by 
displacement of the fragments and injury to the spinal cord, paralysis 
of the upper limbs also is caused, and if the fracture is high enough in 
the region to involve the phrenic nerve directly or by extension death 
follows promptly, preceded by the respiratory symptoms peculiar to 
lesion of this nerve. As the tables quoted from Gurlt show, fractures 
are more common in this region than in any other, and this frequency 
is due especially to the numerous fractures of the fifth and sixth verte- 
brae, which in each case are far in excess of those of any other vertebra 
except the last dorsal and the first lumbar, 

Here too, as after fracture of the atlas and axis, are found cases in 
which the patients present only symptoms of paralysis for a longer or 
shorter time, and then die suddenly of asphyxia in consequence of some 
accidental or intentional movement of the head, which probably causes 
compression of the phrenic nerves by displacement of the fragments. 
Gurlt's tables contain 7 of these sudden deaths ; in 4 of them the imme- 
diate cause was not known or is not indicated ; of the remaining 3 deach 
was caused in one by the barber who turned the patient's head to one 
side while shaving him, in another by the patient's wife who passed her 
hand under his neck and tried to raise him, and in the third by the 
patient's daughter, by putting her arms about him to embrace him. 
Death was accompanied in most of the cases by slight convulsions, and 
took place at periods varying from twelve hours to twenty-three days 
after the receipt of the injury. 

The paralysis in fractures of the portion of this region below the 
fourth cervical vertebra shows many variations. From the relations of 
this part to the brachial plexus it might be expected that paralysis of 
the upper limbs would be a constant symptom, excluding those cases in 
which there is no displacement, but Gurlt's tables show this paralysis to 
have been present in less than one-fourth of the cases, that in the major- 
ity complete paralysis of the lower portion of the body extended upward 
at first only to the middle of the breast, the second rib, rarely to the 
neck, clavicle, or shoulders, and sometimes not even to the umbilicus, 
although it often advanced to a higher point later in the progress of the 
case. Paralytic symptoms appeared in the arms, as a rule, either later 
on the day of the accident or on the following day. The paralysis may 
be complete in one arm and partial or absent in the other; it may be 
complete of motion and incomplete of sensation, or the reverse ; it may 
be limited to the arm or to the forearm ; or the injury to the nerves 
may be evidenced by abnormal sensations, such as numbness or prick- 
ling in the limb. Hypersesthesia affecting the whole or part of the 
limb is occasionally observed, and is sometimes associated with sharp, 
lancinating, continuous, or intermittent pain, which may be spontaneous 
or may be excitedor increased by the slightest touch of the surface. 
Tonic or clonic spasms are seen somewhat more frequently than hyper- 
esthesia, sometimes limited to the arms alone, sometimes involving other 
muscles also. 

An important consequence of the paralysis is the change in the respi- 
ratory act due to the withdrawal of the aid of the accessory muscles 
when the phrenic nerve is uninjured. As a consequence of the paraly- 



266 FRACTURES OF THE VERTEBRAE. 

sis of the intercostal and abdominal muscles, inspiration is effected by 
the diaphragm alone, and expiration by the weight of the abdominal 
walls and viscera which sink back to the positions from which they have 
been displaced by the contraction of the diaphragm. As, the expiration 
is thus purely passive the patient cannot sneeze or cough strongly, and 
as he is thus prevented from cleaning his lungs of the mucus which 
collects in them it gives rise to plentiful moist lales. If the phrenic 
nerve shares in the injury the diaphragm acts very slowly, perhaps not 
oftener than twice or thrice in the minute, the breathing is noisy or 
sighing, and the shoulders may be slightly raised at each inspiration. 
Sometimes a change in the position increases or diminishes the difficulty 
by modifying the pressure upon the cord. A noticeable slowing of the 
pulse accompanies this defective respiration. The voice becomes weak, 
and speech slow and difficult because of the insufficient volume of air; 
there is a peculiar coloring of the face due to defective decarbonization 
of the blood, to which Bransby Cooper first called attention, and finally 
towards the end of life delirium or coma supervenes. 

The local symptoms are usually few and obscure, often nothing more 
than the pain that is felt at the seat of fracture and is increased by pres- 
sure or motion. In several cases, according to Gurlt, it was impossible 
to detect even after death any deformity or crepitation. In other cases 
there are positive objective signs: an abnormal projection or depression 
of one or more spinous processes, an irregularity on the posterior wall 
of the pharynx produced by the displaced body of a vertebra, lateral 
displacement of one or more spinous processes, and possibly crepitation 
or abnormal mobility. 

The position and mobility of the head vary greatly in different cases. 
In some cases they show nothing abnormal, in others the head can be 
moved freely to either side, but not forward or backward, and in others 
it is held firmly fixed in some one position and any attempt to change 
that position causes pain. This rigidity is due not to change in the rela- 
tions of the articular surfaces, but to the involuntary spasmodic contrac- 
tion of the muscles which is nature's method of preventing the infliction 
of pain by movement of the parts. 

It is apparent that the diagnosis of fracture of this region may be 
difficult or impossible. The most that can be clone in many cases is to 
recognize approximately the seat of the injury. Thus, paralysis or 
symptoms of irritation in the arms, even if they first appear alter some 
delay, indicate a lesion above the second dorsal vertebra, although in a 
few exceptional cases this symptom has existed when the injury was 
lower on the spine, and was then due probably to an associated brain 
lesion or a large collection of blood within the spinal canal. If all local 
and functional signs are absent the diagnosis is of course impossible, and 
the real nature of the injury may be entirely overlooked until the pro- 
gress of the inflammation or a chance displacement of the fragments brings 
it to light. 

A remarkable instance of this form w T as reported by Mr. Simon 1 under 
the title of latent fracture of the spine. A girl fell down an embank- 

1 Surgical Observations, p. 145 ; quoted in Holmes's Syst. of Surgery, Am. ed., vol. 
i. p. 795. 



FRACTURES OF THE VERTEBRAE. 267 

merit and injured her neck. She afterwards walked three miles and 
continued at her occupation in a factory for eleven days. On the 
fifteenth day she was admitted to St. Thomas's Hospital with vague 
complaints of pain and tenderness in the neck, but without deformity or 
paralysis of motion or sensation. Early on the following day she com- 
plained of numbness and twitching in the limbs, especially the lower 
ones, and by the evening voluntary motion was entirely lost in the legs 
and almost so in the arms, and sensation was impaired in both. There 
was also high fever with delirium and tympanites. She died on the 
third day after admission, the eighteenth after the fall. 

The autopsy showed a horizontal fracture of the body of the seventh 
cervical vertebra, gaping a little in front, but with no displacement. The 
vertebral canal contained, outside the dura mater, throughout its entire 
length from two inches below the foramen magnum, a large quantity of 
pus which had spread somewhat along the tracks of the nerves at the 
inter-vertebral foramina, and had actually emerged through the foramen 
between the first and second dorsal vertebras. There was no softening 
or change recognizable by the microscope in the spinal cord. 

A similar case is reported by Erichsen. 1 A woman was admitted into 
University College Hospital suffering from the effects of a fall upon the 
back, the symptoms attending which were obscure. There were no head 
symptoms, no head injury, and no paralysis; but she complained of pain in 
the neck, and kept the head, fixed immovably. A few days after admis- 
sion, whilst sitting up in bed, she was startled by a noise, turned her 
head suddenly to learn the cause, and fell back dead. 

At the autopsy it was found that the spinous process of the fifth 
cervical vertebra had been broken off at its root. By the sudden move- 
ment it was forced into the space between that and the adjoining ver- 
tebra, compressed the cord, and caused death. 

In two of Gurlt's cases, fractures of the fifth and sixth cervical verte- 
brae, the vertebral artery on one side was torn, with free escape of blood 
between the muscles and into the vertebral canal. 

The prognosis is extremely unfavorable. Gurlt's tables contain 96 
fatal cases, and only 8 which ended in recovery, and in one of these the 
symptoms reappeared after a fall and the patient died in consequence. 
In one-third of the cases death took place within the first four days ; in 
20 between the fifth and twelfth days : in 11 between the thirteenth and 
thirty-sixth ; and in one case the patient survived five months. 

Fractures of the lower ten Dorsal and first two Lumbar T r ertebrce. 
— This region includes another point at which fractures are very com- 
mon, the lower dorsal and the first lumbar vertebrae. Its position below 
the original of the brachial plexus prevents the involvement of the arms 
in the paralysis except in rare cases where this unusual extension is due 
apparently to the spread of inflammatory softening of the cord or to the 
pressure of extravasated blood. Paralysis of the lower limbs, the blad- 
der, and rectum, which is one of the common results of fracture in this 
division as well as in the higher ones, may be entirely absent at the 
beginning, especially after fracture of the second lumbar vertebra, or, 

1 Concussion of the Spine, p. 50. 



268 FRACTURES OF THE VERTEBRAE. 

more frequently, maybe incomplete, the motor paralysis being as a rule 
more marked than the paralysis of sensation. The latter may extend as 
high as the lower part of the heart, or may stop at the groin, and some- 
times even does not reach above the lower part of the thigh. A common 
result of the paralysis is the immediate retention of urine and feces, 
followed, as before mentioned, by incontinence and by alkaline decom- 
position of the urine and cystitis. This incontinence persists until death 
takes place or improvement begins. The disturbance in the function of 
the bowels aided by the flaccidity of the abdominal muscles produces 
tympanites which makes its appearance usually within a day or two and 
may be sufficiently marked to interfere with respiration by crowding the 
diaphragm upwards and opposing its contraction. 

In other cases, even of apparently severe injury to the body of a 
vertebra, there may be an entire absence of paralytic symptoms and 
even of those of meningeal irritation. Erichsen 1 narrates the case of a 
young man who was caught in a turn-table which doubled his body for- 
wards and caused intense pain in the back. After remaining a few 
weeks in hospital he was discharged. His symptoms were inability 
to stand upright or to walk for more than half an hour, because of the 
pain it caused in the back and under the ribs. The spinous processes 
of the tenth and twelfth dorsal vertebras projected, and there was a dis- 
tinct depression between them. The spinous process of the eleventh 
dorsal was broken off and twisted so as to lie directly across to the left 
side. When lying on his back the patient was unable to rise without 
the "aid of his hands. The legs were wasted, their sensibility and reflex 
irritability normal. No tinglings, no paralysis of the sphincters, no 
sensation of a cord about the body. Muscular reaction to the interrupted 
current equal in all muscles. 

Another case, in which symptoms were almost entirely absent, was 
reported by Dr. Basling in the Lancet, Feb. 4, 18&2, page 186. The 
patient, a middle-aged man, had his back forcibly bent while driving 
under an archway. The only symptoms were slight pain in the back 
and increase of the interval between the ninth and tenth dorsal spinous 
processes. He died on the nineteenth day of injuries inflicted at the 
same time upon the thorax. " The pedicle on both sides of the tenth 
dorsal vertebra was broken close to the body, and the spine was tilted a 
little downwards ; the fracture also extended transversely through the 
middle of the body of the vertebra without causing displacement, and 
without rupturing the anterior or posterior common ligaments. On the 
external surface of the dura mater, opposite the seat of fracture, there 
was a deposit of lymph the size of a shilling. The other membranes 
and the spinal cord itself were quite healthy." 

The diagnosis is aided by objective symptoms, which are more marked 
and distinctive than those found after fractures of the upper portion of the 
column, because as the fracture in the great majority of the cases in- 
volves the body of the vertebra, and is comminuted or accompanied by 
displacement, there is usually a recognizable deformity consisting in an 
angular change in the long axis of the spine, with projection of the spin- 

1 Concussion of the Spine, p. 123. 



FRACTURES OF THE VERTEBRA. 269 

cms process of the broken vertebra or of the one immediately above it. 
This change in the position of the spinous process is sometimes so marked 
that the finger can be pressed deeply in between it and the next lower 
one. 

The prognosis, as regards both life and recovery of function, is more 
favorable than after fracture at a higher point. Gurlt's statistics con- 
tain 145 cases, of which 39 recovered more or less completely ; in 18 
additional ones the patients survived more than three months, with a fair 
prospect of recovery, but died in consequence of some complication that 
had no necessary connection with the fracture. In 23 of the fatal cases 
other severe injuries or complications were present, and apparently 
caused death. Of the 83 fatal cases which remain after excluding these 
23, 1 died in the first twenty-four hours, 33 in the first month, 23 in the 
second, 8 in the third, and 2 in the fourth ; in 16 the patients survived 
for periods varying between four and fifteen months. 
i Fractures of the loiver three Lumbar Vertebra? . — Fractures of this 
portion of the spine are, according to Gurlt's statistics, exceedingly 
rare. 1 The absence of paralytic .symptoms and recognizable displace- 
ment would make the diagnosis during life practically impossible. 

As this portion of the spinal canal contains only nerve trunks, which 
are better fitted by their texture and comparative independence of each 
other to resist or escape damaging pressure by displaced fragments than 
the spinal cord itself is, paralysis may be absent even when the dis- 
placement is marked; in some cases it has been complete, both of motion 
and sensation, over the limbs and abdomen. Mr. Shaw 2 observed four 
cases of fracture in this region in which there was total absence of 
paralysis ; in the first the displacement was so great that the spinous 
and transverse processes projected visibly, the spine could not be straight- 
ened, and the patient's body remained permanently much bent, yet 
motion and sensation were retained from the first. In another there 
was relatively greater prominence of the displaced vertebrae fourteen 
years afterwards than at the time of the accident, when the patient was 
eight years old, u but the column was, on the whole, nearly straight, 
and his muscles were powerfully developed." In another case Mr. 
Shaw "found the trunks composing the cauda equina lifted one-third of 
an inch on a bridge of bone formed by the displacement of a fractured 
lumbar vertebra ; but they were in no degree compressed, and showed 
scarcely any trace of injury." 

The patient may, however, be unable to walk in consequence of the 
loss of support occasioned by the fracture, or he may walk only feebly 
and in a bent posture. But if union takes place, even if the deformity 
persists, he may be as strong and capable as before. In short, the 
prognosis is favorable as regards both life and function. 

1 If the specimens of supposed ununited fracture of the arch of these bones, which 
have been found upon the dissecting-table, in museums, and in old Indian graves, are 
accepted as such, they raise the question whether similar fractures are not more com- 
mon than has been supposed, and whether they may not be present, without dis- 
placement, in some of the severe, so-called strains of this region. I incline to the 
belief, however, that they are specimens of arrest of development. 

2 Holmes's System of Surgery. Am. ed., vol. i. p. 804. 



270 



FRACTURES OF THE VERTEBRAE. 



Fiff. 141. 



Course and Terminations. — The course and terminations of fracture 
of the spine, with their many variations as regards both the life and 
principal functions of the patient, have been indicated in the preceding 
paragraph ; we have now to consider the changes effected in the broken 
bone by the process of repair, and to describe some of the later symp- 
toms with mor« detail. 

Repair takes place as after fracture of other spongy bones, that is, by 
a callus which may remain fibrous or become bony, and may be larger or 
smaller according to circumstances. As the displacement cannot be 
reduced the fragments must unite, if at all, in the positions in which 
they are left by the accident, and although the normal relations may be 
thus notably altered and the union remain fibrous the solidity is quite 
sufficient. The spinous processes frequently unite only by fibrous tissue 
and remain movable ; and sometimes they show a real pseudarthrosis, 
with capsular ligament and smooth surfaces, although it is questioned by 
some if this condition has originated in a fracture. In fractures that 
have been healed for a long time is found the same absorption of pro- 
jecting angles and surfaces which has been noticed in connection with 
other fractures, and this absorption is especially marked in the bodies of 
the vertebrae. If several adjoining vertebrae are broken at the same 
time the intervertebral disks disappear in part by absorption, and the 

remaining portions undergo partial or 
complete ossification, uniting struc- 
turally with the vertebrae, and thus 
forming a more or less extensive, rigid, 
bony mass (fig. 141). The length of 
time required for consolidation ap- 
pears to be greater than for that of 
other spongy bones, probably because 
the immobility of the parts is not so 
complete. 

A number of instances, of complete 
pseudarthrosis have been recorded, 
and their origin differently interpreted. 
Gurlt has collected 21 such cases : 
1 of the odontoid process, 4 of the 
spinous processes of the cervical, dor- 
sal, and lumbar vertebrae, and of the 
sacrum, 3 of the transverse processes of 
lumbar vertebrae, 11 of the arches of 
lumbar vertebrae, and 2 of the side of 
the upper false vertebra of the sacrum. 
Meckel considered the 11 cases in- 
volving the arches of lumbar vertebrae 
as instances of arrest of develop- 
ment, comparing them to the vertebrae 
of some reptiles, which consist nor- 
mally of a separate body and arch, 
and in which many of the processes also remain ununited. Otto opposed 
this view, because the position of the false joint does not correspond to 




Ankylosis by fusion of the vertebr; 
fracture. 



after 



FRACTURES OF THE VERTEBRJS. 271 

that of the line between the diaphysis and epiphysis, and Wyuian, 1 who 
reported 11 additional cases, and did not know of these earlier ones, 
held the same opinion for the same reason. Gurlt accepts Meckel's 
opinion concerning the arches of the lumbar vertebrae, and claims that it 
is probably true also of the other cases. His reasons are that there is 
no trace of injury to other parts, and that it is known that fracture lim- 
ited to a vertebral arch, a spinous or transverse process, is exceedingly 
rare; -that most of the cases relate to the lowest lumbar vertebne, 
fractures of which, of any kind, are rare, and in the case of the fifth 
unknown ; and that the identity of the position of the joint in all corre- 
sponding cases, and its perfect structure, point strongly to an arrest of 
development, and are incompatible with a fracture by external violence. 
Wyman says of his specimens that " the opposing surfaces of bone have 
the usual roughness, and in some instances the neighboring parts are the 
seat of irregular bony deposits. In two the surfaces have been worn 
smooth by mutual friction." Sir Charles Bell 2 mentions and describes 
another, apparently lumbar, vertebra, which he thought " must have suf- 
fered violence of the nature of a diastasis in childhood." " The spinous 
process is separated [on each side] from the transverse process, so as to 
divide the ring which forms the canal of the spine. The surfaces are 
rounded and smooth, showing that they were united by ligament and 
permitted a certain motion." 

Suppuration at the seat of fracture, which is very rare in other bones, 
seems to be more common after simple fracture of the spine, and is at- 
tributed by Gurlt to the greater complexity of the anatomical conditions 
and to the less perfect immobility maintained during the progress of the 
case. His statistics contain eight cases in which, excluding instances of 
suppurative meningitis, more or less pus was found after death at the 
seat of fracture ; in four of the cases the abscess was large, and its walls 
formed in part by the unbroken ligaments, in one of them the wall of 
the abscess had ossified. Usually the intervertebral disks are partly 
destroyed, the 'articular surfaces eroded, and sometimes the bone cari- 
ous. In most cases the suppuration was limited to the fracture, but in 
one the pus had made its way out by several channels through to the 
muscles and tendons, and had collected in the back. 

Inflammation of the end or its envelopes as a consequence of injury 
to the spine is comparatively infrequent ; when it occurs it may be con- 
fined to the outer side of the dura mater, creating adhesions between it 
and the bone, or ending in suppuration, or it may occupy the inside of 
this sheath, and then be the result either of injury to the cord or, more 
rarely, of a spinal meningitis without injury to the cord or any paralytic 
symptoms. In the latter case, the first symptoms are those of irritation 
in the form of spasmodic twitchings in the limbs, and are followed by 
paralysis due to compression of the cord by the increasing exudation. 
With this may come delirium, repeated chills, and sweating. Abscesses 
within the substance of the cord are extremely rare ; only one instance 
is contained in Gurlt' s statistics. As to the recovery of the cord after 

1 Boston Med. and Surg. Journal, Aug. 14, 1889. 

2 Injuries of the Spine, pp. 28 and 83, and plate iii., figs. 5 and 6. 



272 FRACTURES OF THE VERTEBRAE. 

injury, with restoration of function, nothing definite is known beyond 
the fact that a number of autopsies made at various periods after injury 
have shown the cord more or less completely divided, or reduced to pulp 
at the compressed part, or replaced by fibrous tissue. There is nothing 
to prove that a disintegrated portion can be restored, or that divided 
cords can be reunited, and it is not easy to see how proof of such a fact 
could be furnished except by experiment. In those cases in which 
paralysis has disappeared after a time, it is impossible to know exactly 
what was the nature of the lesion of the cord that caused it. 

The troubles created by paralysis of the bladder are very serious, and 
often hasten a fatal termination. They begin, usually promptly, with 
retention, which if not looked for by the surgeon may pass unnoticed, since 
it gives the patient no pain, until the distension of the bladder has be- 
come so great that the urine begins to dribble away through the urethra. 
This distension is of itself sufficient to cause cystitis. If the retention 
is noticed, and the catheter used regularly the appearance of the cystitis 
will be delayed ; the urine gradually becomes turbid, ammoniacal, and 
charged with mucus, and remains so until death or until improvement 
has taken place in the paralysis. After a period that is usually short, 
the retention passes into incontinence, either complete or by overflow. 
The symptoms and usual consequences of the cystitis are such as are 
commonly observed when the same affection is excited by other causes, 
and do not require a detailed description here ; but in addition to these 
common ones there are occasionally observed others of great gravity, 
such as sloughing of the wall of the bladder, and pericystitis with forma- 
tion of abscesses. In one of Gurlt's cases, there was found at the 
autopsy a sac filling the pelvis and reaching half way to the umbilicus, 
and containing nearly a pint of offensive pus and urine ; its wall was 
dark colored, and from it hung numerous soft putrid shreds, the only 
remains of the bladder. The prostate projected half an inch into this 
cavity, and the urethra was pervious. A fistulous opening above Pou- 
part's ligament led into the cavity. The ureters and pelves of the kid- 
neys were enlarged and contained purulent urine. 

In exceptional cases the bladder wall may be found hypertrophied 
and its cavity contracted. In two such cases, the patients were 3i and 
36 years old, and survived 52 and 33 days. The thickening of the wall 
was doubtless inflammatory and not a true muscular hypertrophy. 

In a few cases a very notable diminution in the quantity of urine has 
been observed, not more than three or four ounces being secreted in the 
twenty-four hours. The ammoniacal condition of the urine is due to 
fermentative changes carried on within the bladder, and not to a modi- 
fication of the urine itself as secreted. In a few cases it has remained 
unchanged in the bladder, and in others it has changed spontaneously 
from clear and acid to turbid and alkaline and back again several times. 

Every effort should be made to delay the appearance of this compli- 
cation and to diminish its severity, and with this object the water must 
be regularly drawn as soon as the first signs of retention appear. It is 
usually sufficient to use the catheter twice a day ; it must be passed 
with even more than the usual precautions and gentleness because the 
patient's insensitiveness creates an additional risk of doing damage un- 



FRACTURES OF THE VERTEBRA. 273 

wittingly to the urethral wall. After cystitis has appeared and the 
urine has become turbid, the bladder should be washed once or twice a 
day, preferably by the aid of a fountain syringe, with warm water either 
pure or containing carbolic acid, borax, or quinine, or, if decidedly 
ammoniacal, a little dilute nitric acid. 

Bed-sores appear promptly after any fracture that has caused para- 
plegia, sometimes as early as the second day. The skin at first becomes 
white, then mottled, and then separates as after blistering ; then the 
deeper part sloughs, and the slough spreads peripherally and in depth. 
The commonest seat is the skin covering the convexity of the sacrum, 
then other prominent points upon the back and legs. ISTot infrequently 
when the slough over the sacrum separates the bone underneath is 
found necrosed, and in one instance the fall of this sequestrum opened 
the vertebral canal, with a fatal result. The cause of this early slough- 
ing has been thought to lie in injury to nerves or nerve centres presid- 
ing over the nutrition of the parts ; but Mr. Shaw 1 explains it by the 
pressure which is continued for a length of time and with an absence of 
interruption unknown except in connection with paralysis. Not only is 
the patient unable to move, but he is insensitive to the prolonged pres- 
sure, and does not seek to change his position or to have it changed. 
He lies absolutely motionless in one settled position ; the pressure 
interrupts the circulation at certain points, and, if this interruption con- 
tinues unrelieved, the part dies. The presence of urine or liquid feces 
may prove an additional source of irritation, as may also creases or 
irregularities in the bed-clothing, and lack of attention and scrupulous 
cleanliness. The rapid improvement which sometimes takes place in 
these sloughs, even when the paralysis remains complete, as soon as the 
consolidation of the fracture is sufficiently advanced to allow the patient 
to be readily moved, is an additional demonstration that they are due to 
the pressure and not to the paralysis. Some cases which have recovered 
with permanent paraplegia have shown, on the other hand, a very 
marked tendency to the formation of sloughs on slight provocation. 

Bed-sores are a serious complication, for the suppuration is exhaust- 
ing, increases the difficulty of nursing the patient properly, and involves 
the risk of pyaemia. Their formation may sometimes be averted, or 
least delayed, by painting the exposed parts with flexible collodion ; 
but the best means of preventing them, or of healing them when formed, 
is the use of water beds or cushions which equalize and distribute the 
pressure. Pressure may be taken temporarily off parts which threaten 
to slough by the use of inflated rubber-rings or of several thicknesses of 
plaster placed on each side of the affected part. Great care must be 
taken to keep the sheet on which the patient lies smooth and dry, and 
to protect the perineum and buttocks from being soiled by dribbling 
urine and feces. 

In those cases in which the patients survive the injury and its more 
immediate consequences, it is sometimes found that the paralysis grad- 
ually diminishes and may even disappear entirely. The beginning of 
the improvement is marked by the appearance of sharp darting pains in 

1 Holmes's Syst. of Surg., Am. ed., vol. i. p. 810. 
18 



274 FRACTURES OF THE VERTEBRAE. 

the limbs and of muscular twitchings excited by slight causes, such as 
pinching or touching the skin ; then the power of voluntary motion 
returns, first in one muscle, then in another, usually manifested first by 
movements of the toes, for the great majority of the cases of improve- 
ment and even of survival are those in which only the lower limbs are 
paralyzed. Sensation returns usually before motion ; the bladder is 
found to be again able to retain a certain quantity of urine and to expel 
it with some force ; and a similar improvement is presented by the rec- 
tum, although, as a rule, even in the best cases, the functions of the 
rectum and bladder remain partially and permanently disabled. There 
is usually partial incontinence of both urine and feces. The improve- 
ment in the paralysis may be very slight, or it may go on to complete 
restoration of function, or it may be arrested at any intermediate stage. 
Cases have been referred to in which a permanent deformity existed, 
but the functions of the body and limbs were in no manner disturbed by 
it. Finally, in one or two cases, secondary fracture has occurred and 
caused death. 

Treatment. — While the indications for treatment are the same as in 
other fractures — to reduce the displacement and maintain. the reduction 
until repair shall have taken place — they can rarely be efficiently met, 
and are, moreover, associated with many others affecting the patient's 
life or comfort. 

When a fracture is first received it is important, and especially so if 
the fracture occupies the cervical spine, that no movement should be 
communicated to the fragments which might increase their displacement 
or create a fresh one ; the patient should therefore be handled very 
carefully, and his head and neck should be supported in case of need 
upon a large firm pillow that will immobilize them. Shaw recommends 
for this purpose a sac or pillow-case filled with sand. If there is much 
displacement, an attempt may be made to overcome or diminish it by 
cautious extension, applied either by the hands or by a weight and 
pulley, and aided by cushions or pads placed so as to make lateral 
pressure (coaptation), and frequently shifted so as to avoid sloughing. 
The gypsum-jacket has been recently employed to support the trunk 
during repair, and some interesting and successful cases have been re- 
ported. Kiister, 1 of Berlin, reported four cases at the Congress of the 
German Surgical Association, in three of which much benefit had resulted. 
In all, suspension was made under chloroform, and the angle forcibly 
straightened by pressing it forward until the bone was felt to yield with 
a snap ; then permanent extension (22 pounds) was applied to the 
head. This was followed by gradual improvement of the paralysis, and 
was repeated tw T ice. The discussion that followed brought to light the 
fact that the method had been employed not infrequently (as early as 
1862 by von Langenbeck) and with a fair measure of success, but most 
of the surgeons thought its use should be restricted to the less severe 
cases. Berkeley Hill 2 has recently reported a successful instance of 
its use after fracture in the lower dorsal region, and Drs. Hodgen and 

1 Supplement Centralblatt fur Chirurgie, 1881, No. 20, p. 33. 

2 Med. Times and Gazette, 1881, vol. i. p. 388. 



FRACTURES OF THE VERTEBRA. 275 

Ashhurst have used it to give support to the trunk so that the patient 
could be placed in a chair during the day. I have tried it twice in 
cases of fracture in the lower dorsal region in adults, but Avithout bene- 
fit. In making extension by suspension the patient must be carefully 
watched and the traction increased very cautiously ; in one case I found 
it necessary to make very limited extension by placing the patient upon 
a plank and raising him from the horizontal to the inclined position, the 
shoulders being fixed to the upper end of the plank, and the weight of 
the lower limbs making the extension. Instead of making the jacket in 
the usual manner by many turns of a roller-bandage, it is better to take 
eight or ten thicknesses of gauze of suitable size and shape, soak them 
in plaster- cream, pass them under the trunk as the patient lies upon the 
plank, and then fold them around so as to overlap in front while exten- 
sion is maintained. 

Strychnine and ergot, the latter in large and increasing doses, are 
thought to aid improvement ; and electrical stimulation of the muscles 
may be profitably employed to prevent their degeneration, while the 
restoration of the functions of the nerves is waited for. Bloodletting 
and surface irritation are to be avoided. 

Operative interference, other than that of extension to overcome dis- 
placement, has been limited to the removal of splinters after gunshot 
fracture and to the removal of the spinous processes and adjoining por- 
tions of the arches of one or more vertebrae to relieve pressure upon the 
cord. So far as is known the first operation of either kind was by Louis 
in 1762 ; an officer had received a shot in the back which caused para- 
lysis of the lower limbs and retention of urine. Louis enlarged the 
wound on the fourth or fifth day, and removed the ball and several loose 
splinters.; the patient recovered, but his legs remained weak and small. 
Twenty-four similar cases are reported in the Medical and Surgical His- 
tory of the War of the Rebellion (Part First, Surgical Volume, pp. 455 
and 459), of which only ten died. In nine of the successful cases " the 
spinous process alone or portions of it only were removed, and that the 
injuries to the vertebral column could not have been of a very serious 
nature is shown by seven of the patients having been speedily returned 
to duty or exchanged." " In the five cases of recovery in which por- 
tions of the laminae or of the transverse processes were removed, the 
results were much less satisfactory, and nearly all of the patients still 
suffer from serious disabilities." 

The conversion of a simple into a compound fracture by incision, in 
order to remove fragments that press upon the cord or to replace dis- 
placed vertebrse, is mentioned in the writings of some of the older sur- 
geons, as far back even as Paulus iEgineta, and is spoken of by some as 
if it had been actually performed ; but the first positively known instance 
is the one in which Cline, 1 in 1814, performed the operation after frac- 
ture of the seventh, eighth, and ninth cervical vertebrae, the spinous pro- 
cesses and adjoining portions of the arches being forced in upon the cord. 
Dr. Ashhurst 2 has collected forty more or less well-authenticated cases, of 

1 New England Journal of Med. and Surg., January, 1815.. 

2 Princ. and Pract. of Surgery, 2d ed. 1878, p. 336.. 



276 FRACTURES OF THE VERTEBRAE. 

■which only three were said to have been relieved. The propriety of the 
operation has been discussed with much warmth upon both sides, especi- 
ally between Sir Astley Cooper and Sir Charles Bell in the early part 
of this century. Of late years its chief advocates have been Brown- 
Sequard, Nunneley, and Felizet, while the authors of most of the syste- 
matic treatises upon Surgery or Fractures have withheld their approval. 
While I believe that the danger of the operation has been considerably 
overstated by its opponents, and that it might be still further diminished 
by the use of the antiseptic method, still, as in many cases the necessary 
change in the position of the parts cannot be effected, because the pres- 
sure upon the cord which it is desired to relieve is made in front by the 
inaccessible body of the vertebra, and as the diagnosis must always 
remain somewhat uncertain and incomplete, I do not believe that sur- 
geons will feel justified in undertaking it except under rare circum- 
stances, such as fracture in the cervical region with a fair probability of 
finding that the pressure upon the cord is due to a displaced spinous pro- 
cess. In the dorsal and lumbar regions the fracture, even when due to 
direct violence, usually involves the body of the vertebra, and if pressure 
is made upon the cord in consequence it is made in front and not behind, 
and its seat is outside the field of a prudent operation. It is certain 
that better results have been obtained by suspension and the plaster 
jacket than by trephining, and if the promise held out by the few cases 
in which the former method has been tried should be confirmed by fur- 
ther experience there would seem to be no reason to have recourse to 
the other. 

The operation has usually consisted in a long incision in the median 
line, through which the spinous processes and arches were exposed ; the 
latter were then cut through with saws, trephines, or forceps, and the 
spinous process lifted out. It has been proposed to accomplish the 
same result by passing a stout hook through the skin, engaging it in- or 
under the depressed portion, and then drawing upon it until the displace- 
ment is overcome, but I am not aware that the attempt has ever been 
made. 



FRACTURES OF THE NOSE. 277 



CHAPTER XIV. 

FRACTURES OF THE BONES OF THE FACE. 

1. Fractures of the Nose. 

Under this term we include not only the two nasal bones, but also 
those upon which they rest, the septum, the nasal process of the supe- 
rior maxillary, and the nasal spine of the frontal. The fracture may 
involve one or both nasal bones or adjoining processes ; it may be simple 
or compound, multiple or comminuted ; and it may be associated with other 
fractures of neighboring bones, the most important of which is fracture 
of the cribriform plate of the ethmoid. In the great majority of cases 
the fracture is a more or less comminuted one, occupying the lower half 
of the nasal bones, the main line of fracture running transversely or 
obliquely, and the fragments are displaced backwards or backwards 
and to one side, according to the direction of the force that has pro- 
duced the injury. In rare cases the fracture involves only one nasal 
bone, with or without displacement of the lower fragment, or there 
may be dislocation of one or both bones. Gurlt collected three cases 
of this dislocation or diastasis, two of one bone, and one of both bones. 
The cases in which the blow has fallen upon the upper portion of the 
nasal bones and has fractured the cribriform plate of the ethmoid or 
the nasal spine and adjoining parts of the frontal are rare, and belong 
among fractures of the skull rather than among fractures of the nose. 
The perpendicular plate of the ethmoid is so slight and so flexible that 
it will itself break or bend before it can transmit a fracturing force to 
the cribriform plate. The cartilages which form the alae may be broken 
or torn from their attachments to the bone, and that which forms the 
lower part of the septum is frequently broken in connection with frac- 
tures of the bones themselves. 

Dr. Hamilton 1 says that of the twenty-five cases mentioned in his book 
only fourteen were seen by a surgeon in time to receive treatment, and 
he urges therefore that the possibility of this injury should always be 
borne in mind, and that search should be made for it whenever there is 
reason to suppose that it may be present. The symptoms by which it 
may be recognized are deformity, mobility, and crepitus. The swelling 
of the soft parts, which appears promptly and is usually sufficient to 
completely mask the outline of the parts, may make the diagnosis diffi- 
cult, and the sensitiveness of the mucous surface of the nostrils is such 
that any exploration from that side meets with many objections and 
perhaps the positive refusal of the patient to allow it. Still, unless the 
swelling is very great and the displacement very slight the deformity 

1 Loc. cit. , p. 101. 



278 FRACTURES OF THE BONES OF THE FACE. 

will be recognized ; and indeed the ease with which it is recognized in- 
creases the desirability of reducing it, for any irregularity in a member so 
prominent as the nose is certain to attract attention, and may become the 
source of much annoyance to the unfortunate patient. ' 

Other symptoms which may be present but which are by no means 
pathognomonic, are free bleeding from the nose, and occasionally em- 
physema of the eyelids and face. Bleeding is often severe and some- 
times recurrent and difficult to arrest, but rarely endangers life. Em- 
physema generally has its origin in an eifort of the patient to blow his 
nose ; the air is forced into the subcutaneous cellular tissue through a 
rent in the mucous membrane and periosteum and spreads promptly to 
the eyelids and sometimes over the rest of the face. 

It is so important that a fracture should be recognized and its dis- 
placement corrected, that an anaesthetic should be used if a thorough 
exploration cannot be made without its aid, and the surgeon should spare 
no pains to satisfy himself as. to the condition and position of the bones. 
The examination cannot prudently be postponed, for the bones of the 
face unite promptly, and more than once it has been found impossible to 
correct a displacement after eight or ten days had elapsed ; firm union 
may be expected within a fortnight or three weeks. 

An occasional symptom, when the fracture has extended into the 
adjoining portion of the superior maxillary bone, is obstruction to the 
flow through the lachrymal duct in consequence of its inclusion in the 
line of fracture. Another and more common one is the difficulty or im- 
possibility of breathing through the nose, the result of inflammatory 
swelling of the mucous membrane : and, finally, in the comminuted frac- 
tures that are or have become compound, suppuration may be maintained 
for weeks or months until all the necrosed fragments have worked their 
way out or have been removed. It occasionally happens, too, that after 
a simple fracture a tendency is manifested towards inflammatory compli- 
cations in the neighborhood, abscesses form in and about the nose, por- 
tions of bone or cartilage become necrosed and are exfoliated, and a 
constant purulent discharge from the nostrils is maintained by carious 
bone or persistent ulcers, 

The prognosis as regards life is favorable, except in those cases in 
which the skull is at the same time broken, and in those few others in 
which recurrent hemorrhages, of which no satisfactory explanation is 
given, show themselves. But as regards the avoidance of deformity the 
outlook is not so favorable, because it is not always easy to recognize or 
correct a displacement through the swollen tissues, and the persistence 
of even a slight one is likely to be a very noticeable blemish. In those 
cases in which there has been loss of substance or in which the nasal 
bones remain depressed to the level of the superior maxillary bones the 
deformity is extreme. 

The treatment consists mainly in the reduction of the displacement, 
for it is seldom possible to apply any apparatus or dressing that will 
prevent a recurrence of the displacement if there is any tendency towards 
it. The reduction is accomplished by pressure made from within the 
nostril, aided by manipulation or modelling of the fragments on the out- 
side. The interval between the septum and the side of the nose at the 



FRACTURES OF THE NOSE. 279 

part of the nostril corresponding to the nasal bone is small, so small that 
it will not ordinarily admit an instrument as large as a female catheter, 
and therefore it is useless to attempt reduction by passing the finger into 
the nostril ; a small strong instrument, such as a steel director, must be 
used, one that is small enough to work within the narrow space next the 
nasal bone, and strong enough to transmit considerable pressure. The 
fingers of the left hand placed upon the nose serve to guide the instru- 
ment and to recognize the degree of reduction that has been obtained. 
Ordinarily there is but little tendency to recurrence of the displacement, 
except when the fracture is comminuted and the septum badly broken ; 
the only forces that tend to change the position of the fragments are the 
swelling of the external soft parts, and the pressure of the air when the 
patient seeks to clear his nose by snuffling or blowing. The older sur- 
geons attached much importance to dressings of adhesive plaster cover- 
ing the nose and designed apparently to keep the bones in place by 
holding up the skin. It does not appear that they serve any other pur- 
pose than that of protecting the parts from further violence. 

The idea of supporting the fragments by pressure from within the 
nostrils suggests itself so readily that it is not surprising to find recorded 
many instances and several varieties in the methods of its use. The 
simpler ones consist of plugs of lint crowded into the nostrils, with or 
without tubes to permit breathing ; the more elaborate ones are arrange- 
ments of rods supported by straps crossing the upper lip, and capable 
of adjustment in length and direction within the nostril so as to hold the 
fragments in place ; they are said to have been efficient in some difficult 
cases. On the other hand, I can find no evidence that the plugs of lint 
serve any useful purpose. I have had no experience with them, but I 
should imagine their adjustment to be difficult, their fixity uncertain, 
and their presence the cause of much discomfort. Instead of trying to 
prevent displacement by such means I should confine my efforts to over- 
coming the displacement once or twice a day, so long as it recurred, 
trusting to the rapidity of repair to soon render such interference un- 
necessary. 

Dr. L. D. Mason 1 recommends a method by which good results have 
been obtained in four cases of extensive fracture. He transfixes the 
nose, after reduction, just below the fragments with a stout needle and 
steadies the pieces with a strip of rubber or adhesive plaster crossing 
the bridge and caught upon the ends of the needle. The needle is left 
in place for about ten days. 

Emphysema needs no special treatment ; it tends to disappear promptly 
and spontaneously by absorption. Swelling may be such as to require 
the use of cold applications or of leeches, and bleeding may be so severe 
as to require plugging of the nostrils. The patient should be cautioned 
against making any forcible inspiratory or expiratory acts, especially 
snuffling and hawking, lest he should displace the fragments or occasion 
a fresh hemorrhage or emphysema. 

For the details of the methods by which deformity due to a badly 
united fracture may be relieved, the reader is referred to works upon 

1 Annals of the Anat. and Surg. Soc, Brooklyn, vol. ii. p. 107, and vol. iii. p. 81. 



280 FRACTURES OF THE BONES OF THE FACE. 

reparative and operative surgery. In some cases it is sufficient to sepa- 
rate the cartilages of the alse from the nasal i>ones by a subcutaneous 
incision and to divide the septum ; in others the displaced bones and the 
septum need to be broken with stout forceps, and in on£ case in which 
this plan failed, Dr. R. F. Weir obtained an excellent result by cutting 
down upon the side of the nose, dividing the bone with a chisel, and 
maintaining it in the desired position for a few days by a rod attached 
to a band about the head. 



2. Fractures of the Malar Bone and Zygoma. 

Isolated fractures of this bone are rare, and, so far as can be inferred 
from the small number of cases in which a direct examination has been 
possible, single fractures are rarer than multiple ones, and the rarest is 
that which is almost a simple diastasis, a separation at the sutures with 
some splintering. Partial fractures involving the lower and outer portion 
of the bone or the margin of the orbit have been observed, and also 
single fractures of the frontal and zygomatic processes, extending possibly 
into the bones with which they articulate. In most cases there is de- 
pression of the entire bone with fracture of the malar process of the 
superior maxilla and crushing of the anterior wall of the antrum, the 
malar bone being displaced inwards towards the antrum or sometimes 
backward into the zygomatic fossa. Pure diastasis of the malar bono 
probably does not exist; it has never been demonstrated by autopsy, and 
attempts to produce it upon the cadaver have always resulted in more 
or less fracturing. Gurlt has collected three cases described as diasta- 
sis, in which the lines of separation apparently followed those of the 
sutures very closely. The principal peculiarity in these cases is in the 
displacement, which instead of being inward towards the antrum, as is most 
common after fracture, was downward and outward in one, and upward 
and inward towards the orbit in another ; and in the third, in which the 
zygoma was not broken or separated, the frontal process of the malar 
bone was displaced forward and a little inward, and there was a depres- 
sion in the lower margin of the orbit at the junction of the malar and 
superior maxillary bones. 

Fractures of the zygomatic arch alone have been caused by external 
violence acting from without inwards, as a fall, a blow of the fist or a 
ball, and in two cases from within outwards, the patient having fallen 
forward upon a stick held in the mouth. Hamilton's experiments upon 
the cadaver indicate that the fracture usually takes place in the tempo- 
ral portion of the zygoma, a little behind the suture. The displacement 
follows the direction of the fracturing force. 

The symptoms upon which the diagnosis must be made are deformity, 
mobility, and crepitation. Unless there is much inflammatory swelling 
or extravasated blood, the deformity, which consists usually in a depres- 
sion or flattening of the cheek just below the outer half of the eye, can 
be recognized by sight and touch, and the irregularity of the line of 
fracture can be readily felt on the margin of the orbit, or, if it extends 
to the malar process of the superior maxillary bone, on the under and 
anterior surface of this process by the finger within the mouth. Mobility 



FRACTURES OF THE MALAR BONE AND ZYGOMA. 281 

and crepitation are perceived more rarely ; the latter can be sometimes 
produced by the movement of the jaw. 

Anaesthesia or a sense of formication in the cheek, nose, upper lip, 
and gum of the corresponding side is sometimes observed, and is due 
to an extension of the fracture along the floor of the orbit, involving 
the infra-orbital canal and tearing or bruising the superior maxillary 
nerve. This symptom may be associated with an extravasation of blood 
in the posterior part of the orbit sufficient to force the eye forwards and 
showing itself also under the conjunctiva and in the eyelids. Bleeding 
from the mouth or nose is occasionally seen as the result of the exten- 
sion of the fracture through the mucous membrane of the mouth or 
antrum. 

When the fracture involves the zygomatic arch, and the fragments, as 
is usually the case, are driven inwards, movement of the jaw may be 
difficult or impossible, either because the masseter has been injured, or 
because the depressed fragments of the arch are forced against the eoro- 
noid process of the inferior maxilla, or into the tendon of the temporal 
muscle. In one case the tip of the coronoid process was broken off by 
the same blow that fractured the arch. Swelling, discoloration, and 
pain are the natural and constant results of the fracture and the bruising 
of the soft parts. 

The natural course of these fractures is towards rapid repair without 
excessive callus, and with gradual disappearance of any difficulty that 
may exist at first in the movements of the jaws. It is seldom possible 
to reduce the displacement completely, because, as has been said, it is 
generally inwards and there is no way of acting very efficiently upon 
the bone, except through a wound of the skin. The attempt must be 
made to move the bone in the desired direction by engaging the end of 
the thumb or finger under it in the zygomatic fossa, introducing it through 
the mouth if the cheek is swollen. It has been proposed, and occasion- 
ally practised, to cut down upon the bone opposite the zygomatic pro- 
cess, divide the fascia overlying the masseter muscle, pass a stout hook 
under the process, and raise the bone by drawing upon it, or to make a 
smaller incision over the body of the bone and screw an elevator into it, 
by which it could then be raised. If the incision is so made as not to 
transform a simple into a compound fracture there can be no serious ob- 
jection to the plan whenever the displacement is sufficient to cause much 
disfigurement, and there is even less reason to refuse to use the existing 
wound of a compound fracture for the same purpose. 

Inward displacement of the zygomatic arch cannot be directly acted 
upon except through the skin. Ferrier raised the bone in a simple frac- 
ture, and Dupuytren in a compound fracture, in this manner. Consider- 
able suppuration followed in the latter case, but the patient made a good 
recovery. In only one of the recorded cases has the displacement inter- 
fered seriously and for any length of time with the movement of the 
jaw T s ; in this one the difficulty increased steadily for some time until the 
patient could barely separate the teeth, and then one morning while 
yawning he felt something snap, and the motion of the jaw at once be- 
came and remained free. 

Outward displacement of the same portion of the bone can be readily 



282 FRACTURES OF THE BONES OF THE FACE. 

corrected by pressure, and that of the body of the bone can usually be 
corrected almost entirely by the same means. No dressings are needed 
other than those designed to favor the repair of the bruised soft parts. 

3. Fractures of the Superior Maxilla. 

While the body of this bone, protected as it is by outlying processes 
and other bones, is rarely fractured, its own processes are not infrequently 
broken or involved in the fractures of those bones with which they are 
continuous. Thus, a blow upon the nose breaks not only the nasal bones 
but also the nasal process of the superior maxilla, and a blow upon the 
malar bone may force in the anterior wall of the antrum on which it 
rests. The fractures are always produced by direct violence, and present, 
consequently, considerable variety in their extent and the parts involved. 
The alveolar process may be broken off in part or entirely by a blow 
received on it or on the teeth. A blow received in front, at or below 
the level of the nostrils, may produce a horizontal line of fracture sepa- 
rating the alveolar and palatal processes from the body of the bone, and 
including also the pterygoid plates. Falls from a height have caused a 
vertical line of fracture or diastasis between the two bones along the 
median line of the mouth, extending even through the soft palate and 
associated with fracture of the malar or nasal bones. Fractures of the 
roof of the mouth are usually multiple, and the most severe ones appear 
to be those caused by a blow received upon the malar bone which has 
crushed in the wall of the antrum. In a case of this kind mentioned by 
Hamilton, an attempt to remove a loose molar tooth u brought down 
several teeth and the whole floor of the antrum," attached to which was 
found, after its removal, a considerable portion of the pyramidal process 
of the os palati. Fractures of the alveolar process, even with much dis- 
placement and mobility, present but little gravity, for they heal rapidly 
and without necrosis. 

It occasionally happens that one or both bones are driven in with 
multiple and comminuted fracturing of them and of the adjoining ones. 
The earliest known case of the kind was reported by Wiseman, and has 
been extensively quoted. The upper jaw was driven in so far that the 
finger could not be introduced between the palate and the posterior wall 
of the pharynx. Wiseman inserted a blunt hook through the mouth and 
easily drew the bone forward into place; as, however, the displacement 
recurred very easily he left the hook behind the palate and had it drawn 
upon constantly by the patient or his friends until consolidation had 
taken place. Quite a number of similar cases (Gurlt has collected up- 
wards of twenty) have been reported, all the result of great violence, 
either by falls from a height or the passage across the face of a heavy 
wagon, or a violent blow. In one case the bones of the face were so 
movable that they moved up and down when the patient swallowed, as if 
they were restrained only by the skin. In most of them the patients 
recovered, and it is worthy of remark, that notwithstanding the degree 
of the violence and the extent of the injury, it seldom happens that the 
fracture involves the skull. The reason lies apparently in the direction 
in which the fracturing force is applied, a direction outside of, and more 
or less parallel to the surface of the skull, and not in the line of one of its 



FRACTURES OF THE SUPERIOR MAXILLA. ^80 

diameters. The bones of the face are, as it were, torn off the skull 
rather than driven back upon it. 

Very extensive mutilation of the face has been caused by gunshot 
wounds, especially in attempts at suicide when the muzzle of the gun 
has been placed within the mouth, but it is rare for ordinary violence to 
lead to much loss of tissue. Malgaigne speaks of the following case as 
unique in this respect in his experience. A lad was kicked in the face by 
a horse ; the superior maxillary, nasal, and palatal bones were extensively 
comminuted, and the skin torn and bruised. Recovery took place, but 
with much deformity. The nasal bones, the anterior portion of the alve- 
olar arch, and the greater part, if not all, of the hard palate had disap- 
peared. There was no longer either nose or mouth ; the lips were 
united by a firm cicatrix, and the mouth and nostrils were represented 
by an oval opening between the nasal processes of the superior maxillae. 
Through this opening the patient breathed, spoke, drank, and ate. 
< The diagnosis of fracture is ordinarily made without any difficulty, 
since large portions of the bone are open to direct examination with the 
finger through the mouth and on the cheek. Irregularity of outline, 
mobility, displacements, and crepitation can be readily recognized. In 
some few cases where there was no displacement the diagnosis has been 
in doubt, and Gue'rin 1 has pointed out a symptom which might be useful 
under such circumstances. It has been said that the pterygoid apophysis 
is always broken when the line of fracture crosses the jaw horizontally 
between the alveolar process and the malar bone, and Guerin found that 
pressure with the finger upon the inner plate of this process caused pain 
and sometimes showed mobility when there was no other sign of fracture. 
It is, however, extremely difficult to recognize the extent of the fracture in 
those comparatively rare cases in which the bones of the base of the skull 
are likewise broken, because they are removed from the range of direct 
examination. As a rule, the diagnosis can be completed only after the 
lapse of the period of time which is necessary to the appearance of the 
grave symptoms to which such extension of the fracture may give rise. 

Repair in cases of average severity takes place in from thirty to forty 
days with a scanty formation of callus, and not infrequently in less time. 
The vitality of the bone is exceptionally great, hence the rule laid down 
by Malgaigne and some of his predecessors, and repeated by all subse- 
quent writers, to leave every fragment that is not absolutely and entirely 
detached. Although the rule is a sound one, it occasionally happens that 
fragments become necrosed, and have to be removed. This is thought 
to happen more frequently with fragments of the alveolar border than 
with any others. 

Displacement is seldom noticeable after repair is completed, except in 
the nose, but it usually exists to a greater or less degree, and the inge- 
nuity and the patience of the surgeon are often severely taxed to over- 
come the constant tendency to the recurrence of the displacement. Sali- 
vation is often profuse, and the discharge offensive. Division of the 
lachrymal canal by the fracture may lead to its obliteration. 

Displacement of the entire bone may be treated as in Wiseman's case, 
or the retention may be aided by securing the lower jaw against the 

1 Archives Generates de Medecine, July, 1866, vol. ii. p. 5. 



284 



FRACTURES OF THE BOXES OF THE FACE 



Fig. 142. 



upper one, ivith or without the intervention of interdental splints or 
moulds of gutta percha, or metal shaped to fit the teeth and alveolar 
arch. Lateral pressure cannot well be made upon the cheeks to over- 
come separation along the median line of the palate, but fortunately it is 
not always necessary. In Simonin's case, quoted by Malgaigne, the gap 
began to contract spontaneously by the tenth day, and was completely 
closed by the thirty-third, with no other displacement than a slight dif- 
ference in level between the two halves. In another case, quoted by 
Hamilton, the gap was large enough to admit the little finger, and was 
still open six weeks after the receipt of the injury. 

After fracture of the alveolar process the fragment should be carefully 
readjusted and fixed by wiring the teeth to the adjoining ones, or by a 
mould of gutta percha or metal. Agnew says he has used for this pur- 
pose with great advantage a piece of cork with 
grooves cut in its upper and low T er surfaces to re 
ceive the teeth of both jaws. The reduction is 
made, the cork inserted, and the jaws firmly bound 
together. No attempt should be made to remove 
the corresponding teeth, for not only are the chances 
in favor of their becoming firm again in their sockets, 
but the attempt to draw them, even if they are loose, 
may materially increase the mischief done by the 
fracture, as in Hamilton's case quoted above, in 
which such an attempt caused the loss of the entire 
floor of the antrum. 

The gutta percha or metal moulds may be held in 
place by binding the lower jaw against it after it 
has been fitted to the upper one, or by an apparatus 
similar to one devised by Graefe for the purpose, and shown in figure 
142. If the splint is to be supported by the lower jaw it should be so 
constructed that an interval will be left through which food can be given 
and the mouth cleaned. 

4. Fractures of the Inferior Maxilla. 




Intra-buccal spliut for 
fracture of the upper 
jaw. 



Fracture of the inferior maxilla occurs more frequently than that of 
any other of the bones of the face. It is rare in childhood and old age, 
most frequent between the ages of 20 and 30, and is apparently more 
than ten times as common in males as in females. 

Gurlt collected 143 published cases in which the character and position 
of the fracture were described with sufficient accuracy to allow of their 
use as statistics ; of these 80 were single, 49 double, and in 14 there 
were three or more lines of fracture. Of 75 single ones (excluding 5 
in which the fracture was limited to the alveolar process) the fracture 
occupied the median line in 25, the region of the incisor teeth in 22, 
that of the back teeth in 15, behind the teeth in 8, and the condyloid 
process in 5. In 35 double fractures both halves of the bone were broken 
20 times, and at points on the two halves corresponding closely with 
each other ; one side alone 8 times, and the median line by one of the 
fractures 7 times. One or both of the condyloid processes were broken 
in several of the multiple fractures. These figures show that, exclusive 



FRACTURES OF THE INFERIOR MAXILLA. 285 

of partial fractures of the alveolar border, which are very common, and 
often caused by the drawing of a tooth, the most frequent seat of fracture 
is at or near the median line, and that single fracture of the ramus, or 
of the alveolar or condyloid process is comparatively rare. They differ 
materially from the estimates made by various writers, but as the latter 
differ quite as much among themselves, and appear to have spoken in 
most cases from general impressions rather than from figures, the prefer- 
ence should be given, I think, to Gurlt. 

Double fractures of the lower jaw are relatively more common than 
those of other bones, while multiple and comminuted ones are rare. 
Compound fractures are common, both because the gum overlying the 
fracture is frequently torn, and because the lip and skin are often in- 
volved in the direct injury that has caused the fracture. The fracture 
is complete or incomplete, the latter rarely except when the alveolar 
border alone is involved. Cases are reported in which a portion of the 
body of the bone adjoining the alveolar border has been broken off; and 
at least one case (Hamilton) which appears to have been an infraction 
in the line of the outer incisor tooth. 

The line of fracture in the body of the bone is usually vertical or 
nearly vertical ; at the angle or in the ramus it is oblique or transverse. 
At the median line there is but little displacement, if any ; but, when 
present, it may be in either of three directions : a difference in the 
horizontal level of the edge of the teeth, a displacement forwards and 
backwards of the fragments upon each other with lateral overriding, or 
a lateral separation of the two. In the fractures between the median 
line and the canine tooth the line is still much more frequently vertical 
than oblique ; but displacement is the rule,' although no one form of it 
seems to be more common than the others. Between the canine tooth 
and the angle of the jaw it is either vertical or inclined backwards and 
downwards, and usually, instead of crossing the bone from without 
inwards at a right angle to the surface, it is inclined backwards and 
inwards, so that the anterior fragment is lengthened on the inner side 
and the posterior fragment on the outer side. The inferior dental nerve 
is crossed by this fracture, as it lies within the bone, and is sometimes 
torn or bruised. 

Fracture behind the teeth is comparatively rare, only eighteen cases 
being contained in Gurlt's statistics, and it is frequently double or 
multiple or associated with other fractures. 
When the fracture lies at the j unction of the 
body of the jaw and the ascending ramus, it is 
usually oblique, running from behind the last 
tooth backwards and outwards towards the 
angle of the jaw ; but it may be vertical. 
Displacement is usually slight or lacking, the 
parts being kept well together by the masseter 
and internal pterygoid muscles. 

Fracture of the condyloid process is usually 
accompanied by other fractures of the same or 
other bones of the face, and may be produced 
by a blow either upon the chin or upon the 

•j /» ,1 • , . . rni i ,. „ Fracture of lower jaw behind 

side ot the jaw near the joint. The line of the teet h. 




286 FRACTURES OF THE BONES OF THE FACE. 

fracture passes through the neck, and the few specimens furnished by 
autopsies and museums do not show a greater frequency at any point 
or in any direction than at any other. 

Dr. Will 1 reported a case with specimen, the patient Jiaving died in 
consequence of an associated fracture of the pelvis. The line of fracture 
was oblique backward and downward from the bottom of the sigmoid 
fossa. The symptoms were few, but the nature of the injury was quite 
evident. There was slight deviation of the chin towards the affected 
side, abnormal lateral mobility, and indistinct crepitus. Examination 
by the mouth revealed displacement of the condyle upward and forward 
by the action of the external pterygoid muscle. Dr. Will adds that, 
according to Heath, there are only six examples of this fracture in the 
London museums. Cases have been mentioned by Soranus, Desault, 
Kibes, Berard, Houzelot, Bichat, Packard, Watson (of N. Y.), and an 
incomplete one of both condyles by Verneuil. 

Fracture of the coronoid process is exceedingly rare. Gurlt's collec- 
tion contains two cases and a reference to a third. In one, both coro- 
noid processes, both condyles, and the symphysis were broken by a fall 
from a height ; in the second, 2 the coronoid process and the condyle 
were broken by a fall from a loft. The patient died of delirium tremens. 
In the third case, the zygoma and malar bone had been driven in upon 
and had broken off the tip of the coronoid process. There was exten- 
sive fracturing of the bones of the face and of the base of the skull. 

A portion of the alveolar process with the teeth in place is sometimes 
broken off. The size of the piece varies within wide limits, and the dis- 
placement is habitually inwards. In one or two entirely exceptional 
cases a similar piece, including a portion of the body of the bone, has 
been broken off. 

In double fractures, the intermediate piece is almost invariably drawn 
downwards and backwards by the unopposed action of the muscles of the 
neck which are attached to it. 

Comminuted fractures, except as the result of gunshot wounds, are 
comparatively rare ; double and treble fractures are less so ; and one 
case is on record in which there were five distinct and separate lines of 
fracture. 

In three of Gurlt's cases the autopsy showed rupture or crushing of 
the inferior dental nerve, and in two the external ear was injured, by 
fracture of its bony wall in one case, and by rupture of its cartilaginous 
portion in the other. 

The most frequent cause of fracture, exclusive of partial fractures 
produced by attempts to draw a tooth, is violence received upon the 
chin ; fracture by pressure upon the sides is much less common, the 
other occurring thrice as frequently. Hamilton mentions a case in 
which a double fracture was produced in a young woman by the grasp 
of her husband's hand. Fracture of the condyloid process may be pro- 
duced in either of the same two ways — a blow upon the chin or upon 
the cheek. Examples of fracture of the coronoid process are too rare, 
and too little is known concerning them to explain their mode of pro- 

1 Lancet, 1882, vol. i. p. 100. 2 Lancet, 1860, vol. ii. p. 536. 



FRACTURES OF THE INFERIOR MAXILLA. 287 

duction. The position of the bone is so sheltered that it can hardly be 
broken by direct violence except after fracture of the zygoma, and, 
although its fracture by the contraction of the temporal muscles has 
been alleged, there are no facts to demonstrate it. 

The objective symptoms of fracture of the lower jaw are the same as 
those of other fractures : abnormal mobility, crepitation, displacement. 
The bone is so accessible to the touch both within and without the mouth 
that irregularities in the outline of its body can be easily recognized by 
the fingers and sometimes by sight. The teeth show differences in 
level, vertically or antero^posteriorly ; those which adjoin the fracture 
are usually loosened and may be entirely displaced ; in one or two 
cases a tooth has slipped or been driven in and lodged between the 
fragments. Mobility and crepitation are detected by manipulation. 
When the fracture is situated at or above the angle of the jaw its recog- 
nition is by no means so easy ; by passing the finger within the mouth 
along the inner and outer surfaces of the ramus, irregularities of outline 
and localized points of pain may be recognized. 

The degree and direction of the displacement vary much. As a rule, 
when the fracture is single and not in the median line, the anterior frag- 
ment tends towards the inside of the mouth, and this displacement is 
favored by the obliquity of the line of fracture which, as above men- 
tioned, usually leaves the anterior fragment longer on the inside than on 
the outside. The causes of the displacement have been the subject of 
some discussion. It has been shown, on the one hand, that the usual 
displacement is produced on the cadaver by the simple action of the 
fracturing force ; and, on the other, by the recurrence of the displace- 
ment after correction, that the action of the muscles is also able to pro- 
duce it. The differences that have been noted by various observers 
corresponding to different positions of the fracture have not proved con- 
stant, and as their causes appear to have been incidental and varying, 
they do not require examination. 

In a case observed by Pierson, 1 a double fracture was occasioned by 
the passage of a wheel across the jaw, and the intermediate portion of 
bone, with the tongue, dropped back into the mouth and throat so as to 
nearly cause suffocation. The patient contrived to draw the tongue 
forward with a spoon and prevent suffocation until the surgeon secured 
the fragment by wiring the teeth. Similar consequences have followed 
resection of the median portion of the jaw. 

Pain on pressure and on movements of the jaw is a constant and well- 
marked symptom, and may be produced also by deglutition. It may 
be extremely severe, and may give rise to nervous and tetanic symptoms 
of much importance when it is due to injury of the inferior dental nerve 
within its canal. Usually injury to this nerve is shown only by anaes- 
thesia of the lower lip and chin on the affected side, usually temporary, 
but occasionally permanent. Malgaigne denies the frequency of such 
injury to the nerve, and says that he has never personally met with an 
instance of it. 

1 American Jonrn. Med. Sciences, 1841, p. 186. 



288 FRACTURES OF THE BONES OF THE FACE. 

There are no recorded clinical facts indicating the symptoms of frac- 
ture of the coronoid process. 

Fracture of the condyloid process was first studied by Desault and 
Bichat, and but little if anything has been added to our knowledge of 
the subject since their time. The symptoms are pain increased by 
motion, diminished mobility of the jaw, often crepitation on manipu- 
lation, irregularities in the region of the condyle, the ease with which 
the condyle can be pushed forward into the zygomatic fossa, its failure 
to share in the movements of the jaw, and its almost constant displace- 
ment upwards and forwards by the contraction of the external pterygoid. 
Ribes pointed out an additional symptom which is sometimes present, 
deviation of the chin towards the affected side. This is effected by the 
displacement of the ramus upwards and backwards on the outer side of 
the condyle and neck, and the more easily if the fracture is a double or 
multiple one. Gurlt quotes the description of a specimen of this kind 
from a work by Bonn, published in 1785. The condyle was united by 
a bony callus to the ramus just above the orifice of the dental canal. 

Swelling of the gums, face, and glands follows promptly upon the 
injury and is often increased by the* direct bruising of the soft parts 
themselves; the secretions of the mouth, increased in quantity by the 
irritation, mingle with the pus that comes from the fracture if compound 
or from the ulcers produced by the stomatitis, decompose, and cause an 
offensive odor that can scarcely be kept under control even by the most 
careful attention. Abscesses may form and open within the mouth or 
upon the sides of the jaw or the neck below it ; they are almost invariably 
associated with the presence of detached splinters or the exfoliation of 
portions of the jaw which require, of course, to be removed before a 
permanent cure can be obtained. Small fragments may long escape 
recognition, and the only indication of their presence may be a fistula ; 
larger fragments force themselves promptly upon the surgeon's attention 
by the profuseness of the discharge and the amount of local irritation. 
In a case reported by Ancelon, 1 of double fracture of the body of the 
lower jaw, the fracture being on one side two centimetres, and on the 
other three centimetres in front of the insertion of the masseter, the 
entire portion on each side behind the fracture became necrotic. Six 
months after the accident the left ramus was cast off spontaneously, and 
the right one was removed by the surgeon. The central piece was pre- 
served, and recovery took place with slight disfigurement. In a case 
mentioned by Desault, fracture of the neck of the condyle was followed 
by necrosis and elimination of the fragment, and in another, mentioned 
by Malgaigne, 2 Monteggia saw suppurative periostitis, total necrosis, 
and death follow fracture caused by a blow with a stick. As a rule, 
however, the vitality of fragments of the lower jaw is great, and necro- 
sis, except of limited points of the alveolar border, is uncommon. 

Simple fractures unite in from thirty to forty days, and even when 
there has been a considerable loss of bone by splintering or necrosis, 
the final result may be a very good one, in this sense, that the jaw is 

1 Gaz. des Hopitaux, 1854, p. 550. Quoted by Gurlt. 

2 Loo. cit., p. 388. 



FRACTURES OF THE INFERIOR MAXILLA. 



289 



strong enough to support artificial teeth in the place of those that have 
been lost by the accident, is sufficiently regular in form to avoid de- 
formity, and is free in its movements. 

Failure of union, pseudarthrosis, is rare. Gurlt's statistics contain 
only two cases which can be properly considered such, and they were 
both cured by operation. It is more common after gunshot fracture 
with much loss of substance by elimination of splinters, and may inter- 
fere with mastication. In a few cases union in a faulty position has 
required an operation to correct the deformity or relieve the functional 
disability. 

The prognosis is a relatively favorable one ; the probabilities are that 
union will take place promptly, that no serious complications will arise, 
and that no important deformity or disability will remain. Danger to 
life may come from two quarters : the proximity of the bone to the 
cranium carries with it the possibility of associated injury to the brain 
or to its case ; retention of pus in a compound fracture in communica- 
tion with the cavity of the mouth exposes to the grave danger of absorp- 
tion of the decomposed secretions and, if the displacement and laceration 
are great, to the burrowing of the decomposed pus along the deeper 
planes of the neck into the anterior mediastinum. 

Treatment. — Displacement following fracture of the body of the jaw 
can usually be readily overcome by the pressure of the thumb and 
fingers upon the teeth and the lower border of the bone; in some cases 



Fig. 144. 



Fig. 145. 





Barton's bandage for fracture of the lower jaw. Gibson's bandage for fracture of the lower jaw. 

the interlocking or wedging of the smaller pieces or of displaced teeth, 
may render the reduction impossible until after they shall have been 
removed, and in a case reported by Buck 1 to the N. Y, Pathological 
Society in which the bone was broken very obliquely, the displacement, 
which amounted to about half an inch, could not be overcome except by 
the division of the soft parts including the lip and the removal of the 
sharp end of the anterior fragment. In another case reported to Dr. 
Hamilton, by Dr. J. H. Packard, it was found necessary to divide the 



19 



Quoted by Hamilton, loc. eit., p. 132. 



290 



FRACTURES OF THE BONES OF THE FACE. 



attachments of the muscles to the lower border of the bone at the sym- 
physis to prevent recurrence of the displacement. 



Fig. 146. 



Fig. 147. 




Garretson's bandage for fracture of the lowei 
jaw. 



Hamilton's bandage for fracture of the lower 
jaw. 



Fig. 148. 



In simple cases where the tendency to displacement is slight it is 
sufficient to immobilize the lower jaw by binding it against the upper one 

with a bandage that passes under the 
chin and over the head and is pre- 
vented from slipping by another car- 
ried over and around the occiput. 
Different forms of bandages, which can 
be used also in connection with inter- 
dental splints, are represented in the 
adjoining figures (figs. 144 to 148). 

Splints are applied either to the 
front and under surface of the jaw out- 
side the mouth, or to the teeth, or the 
inner surface of the jaw, and two kinds 
are sometimes used in combination. 
Outside splints are available only in 
cases in which there is not much tend- 
ency to displacement and in which the 
lateral pressure of a simple bandage 
would cause the fragments to override 
in one direction or another. They 
may be made of leather, pasteboard, 
gutta percha, or plaster of Paris, and 
consist essentially of a cup-shaped piece embracing the chin and ex- 
tending nearly to the angle of the jaw on each side, and to the fold of 
the neck below. A simple method of making one in pasteboard or gutta 




Four-tailed bandage for fracture of 
lower jaw. 



FRACTURES OF THE INFERIOR MAXILLA. 



291 



percha, as described by Dr. Agnew, is represented in figures 149 and 
150. A piece of the material chosen, 4 or 5 inches long and 2 J inches 
wide, is divided longitudinally along its centre for one-third of its length 



Fis:. 149. 





\. 4- / 






1 




1 




2 


3 


2 





Pasteboard splint for fracture of the lower jaw. 



at each end. The halves are then bent at a right angle, the ends 2, 2, 
turned in, and the other ends, 1,1, turned up against them. The chin 



Fur. 150. 





2 \ 




/ 2 
/ 






3 


1 



The same, partly folded. 

fits in behind the part marked 3 in the figures. It may be necessary to 
cut away a portion from the opposite edge (4) to make it fit at the 
throat. 

Interdental splints are made of metal, gutta percha, or vulcanized rub- 
ber ; they are fitted to the crowns of the teeth of both fragments after 
reduction of the displacement, and are held in place either by binding 
the jaws together with an outside bandage, or by braces connecting the 
splint with a pad under the jaw (fig. 151), or by a special arrangement 
of lateral braces as in Kingsley's apparatus (fig. 152), or by fastening 
them to the teeth with wires. Some are fitted only to the broken jaw 
and are intended only to immobilize the fragments on each other ; 
others are fitted to both jaws and enable the upper one to be used as a 
splint for the lower. Those of which the one represented in figure 151 
may be considered the type, give the least firm support and often cause 
much discomfort by the pressure of the pad under the chin, especially 
if the soft parts are bruised and swollen. The upper portion of the ap- 
paratus is a grooved metal plate fashioned to the teeth as accurately as 
possible and designed to overlap the line of fracture ; the lower portion 
is a pad capable of adjustment at any desired point along the upright bar. 

Gutta-percha splints may be made either of thin strips or of thick 



292 



FRACTURES OF THE BONES OF THE FACE 



lumps or wedges, 
they are intended 

Fig. ]51. 



The former have a length of three or four inches, for 
to overlap the fracture, and a breadth sufficient to 
overlap the crowns of the teeth from gum to gum ; 
they are softened by immersion in hot water, 
moulded to the teeth, cooled as rapidly as possible, 
taken off and trimmed suitably. Then the splint 
is reapplied and the jaws bound together. If the 
tendency to displacement is slight the bandage 
may be loosened during the day to allow the in- 
troduction of liquid food, or a wedge may be kept 
between the jaws so as to create an interval to be 
used for this purpose, or advantage may be taken 
of the absence of teeth, especially from the upper 
jaw. Dr. Hamilton refers also to a method of 
fastening the splint employed successfully by Dr. 
J. S. Prout. A plate of gutta percha was moulded 
to the upper surface of the teeth on both sides of 
the fracture and secured by wires previously at- 
tached to the teeth. This method allows the 
In another case quoted by Gurlt 1 two fragments 
of the alveolar border carrying eight teeth were secured by a splint of 
sheet lead moulded to the teeth and fastened down by silver wire, the 
ends of which were brought out under the chin by means of a needle and 

tied over a roll of plaster. The wire 




Splint for fracture of the 
lower jaw. 

mouth to be opened.- 



Fiff. 152. 



in 



caused no irritation and was left 
place forty-seven days. 

Gutta-percha wedges were intro- 
duced by Dr. Hamilton to meet a 
double indication, that of fixing the 
fragments securely and of allowing 
the easy introduction of food. Two 
pieces of gutta percha of suitable 
size are softened and formed into 
wedges and introduced between the 
jaws, the edge of the wedge directed 
backward. The jaws are closed 
upon them, the fragments pressed 
up until the lower border of the jaw 
is straight, and the wedges moulded 
to the sides of the teeth above and 
below. As soon as the gutta percha 
has hardened it is removed, trimmed 
suitably, and reapplied, and the jaws 
are bound together with a bandage. 
Vulcanized rubber is a valuable 
substitute for gutta percha in some difficult cases, but its employment 
requires special skill and experience which are found usually only among 
the dentists. Casts of one or both jaws are first taken in wax ; from 




Kiugsley's splint applied. 



1 Loc. cit., vol. ii. p. 393. 



FRACTURES OF THE INFERIOR MAXILLA. 



293 



these plaster models are made, and upon these latter the splint. Figures 
152 and 153 show the splint as made by Dr. Kingsley, of New York, 



Fig. 153. 




Kingsley's interdental splint. 

with attached bars by which the splint and jaw can be bound firmly 
together, the bandage passing from one bar to the other underneath the 
chin. 

Another method, which dates back to Hippocrates (see page 187), is 
to fasten together the teeth on opposite sides of the fracture by thread 
or wire. In some cases this answers the purpose, but more frequently 
the wires break, the teeth become loose, and the jaws sore. If used, 
two or three teeth on each side of the fracture should be included in the 
loops. 

The teeth have been wired together also in other ways to prevent dis- 
placement ; thus, the lower jaw has been immobilized against the upper 
one by binding corresponding teeth together, or by fastening a back tooth 
of the lower jaw to a front tooth of the upper jaw, for example, or one 
on the left side to another on the right side. In at least one case, where 
a sufficiently firm hold could not be got by wrapping the wire about the 
teeth, the latter were perforated with a drill and the wire passed through 
the holes. 

In a few cases of compound fracture the bones themselves have been 
drilled and wired together as in operations for pseudarthrosis. 

Gurlt 1 quotes two cases in which displacement inward was overcome 
by a metal apparatus fitted to the inside of the jaw and opposing the 
displacement by a screw or a spring. In each case the fracture was on 
the side of the jaw. 

Repair takes place so rapidly that, except in compound fracture with 
much suppuration, there is rarely any tendency to displacement after 
the tenth day, and therefore the discomforts incidental to the continuous 
closure of the jaws do not need to be borne for any great length of time. 
If the importance of the case warrants it, if the displacement can be 
prevented only by keeping the jaws constantly in contact with each other, 
the patient can be fed through a tube passed behind the last molar tooth, 
or through the nose. It has been shown of late that a tube through 
which the patient can be exclusively nourished can be worn permanently 

1 Loc. cit., vol. ii. p. 439. 



294 FRACTURES OF THE BOXES OF THE FACE. 

in the nostril and oesophagus, without inconvenience, for several months. 
Krishaber has done this in one case with a gum oesophageal tube, and 
Verneuil with soft rubber catheters in several cases, for days at a time, 
after operations upon the mouth. 1 There seems to be no reason to 
doubt that the same measure could be employed successfully, in case of 
need, after fracture of the jaw. 

Cleansing and disinfecting washes containing chlorate of potash, borax, 
or alum will be found to add much to the comfort of the patient when- 
ever they can be used. 

After fracture of the neck of the condyle the tendency is to the dis- 
placement of the condyle forwards by the traction of the external ptery- 
goid muscle, and as the fragment is too small to be acted upon directly 
by any dressing this tendency, if manifested, cannot well be overcome. 
The treatment, therefore, is to reduce the displacement if it exists, and 
then to immobilize the jaw after having pressed it backward and upward 
to interlock the fragments. Ribes reduced the displacement by passing 
his forefinger into the mouth and along the inner side of the ascending 
ramus until he reached the condyle and was able to press it back into 
place. Fountain, of Iowa, obtained a good result by drawing the jaw 
well forward and wiring the teeth together, so as to maintain the position. 

Fracture of the coronoid process is not open to any treatment except 
immobilization. 

Fractures of the alveolar border are best treated, like fractures of 
the body, by immobilization after careful reduction of the displacement, 
and it is advisable not to make haste to remove loose or semi-detached 
teeth. They may become firmly adherent again, or, if this should fail, 
they may be removed subsequently without having caused any serious 
trouble or delay. 

Delayed union and pseudarthrosis are to be treated by the removal of 
the cause, if any definite local one exist, or by operative interference, 
freshening of the surfaces of fracture, and wiring of the fragments. 

i Bulletins de la Soc. de Chirurgie, 1881, pp. 220-229, 



FRACTURES OF THE HYOID BONE. 295 



CHAPTER XV. 

FRACTURES OF THE HYOID BONE.' 

This comparatively rare lesion has received the attention of writers 
only within the present century. Malgaigne collected 8 cases, Hamil- 
ton added 2, and Gibb 3 ; in 1864 Gurlt collected 27 cases, 21 being of 
the bone alone, while in 6 there was associated fracture of the thyroid 
or cricoid cartilage or of the trachea. In 3 of Malgaigne's cases and in 
5 additional of Gurlt's the fracture was caused by hanging, judicial or 
suicidal, one of the latter surviving ; in 6 of these one of the greater 
cornua was broken, in the remaining 2 the body. Gibb 1 says that Mack- 
murdo, a surgeon of Newgate prison for many years, found this frac- 
ture only four times on examination of the bodies of those who met their 
death there by hanging. In the other cases of the list the cause was 
violent grasping of the neck, or a blow, or fall, and in two cases appa- 
rently muscular action, general muscular contraction during a fall. Val- 
salva reports a case of " dislocation of one of the greater horns from the 
body," caused by the effort to swallow a large piece of food. 

In the great majority of the cases the fracture was of one of the 
greater cornua, and usually at or near its junction with the body. In 
only three cases was the body of the bone broken, and in none the 
lesser horn. 

The symptoms of fracture of one of the larger cornua, without accom- 
panying injury of the larynx or trachea, are, according to the records, 
quite well-defined and characteristic ; sharp pain at the seat of fracture 
increased by pressure, speaking, or swallowing ; swelling in the same 
region appearing soon after the accident and due in part to extravasated 
blood ; recognizable displacement or mobility of the fragment ; crepita- 
tion ; and sometimes free bleeding into the mouth, the result of perfora- 
tion of the mucous membrane of the pharynx by the bone. Exploration 
of the pharynx will enable the surgeon to recognize displacement of the 
horn inward and perforation of the mucous membrane if they exist. 
The patient is seldom able to move the tongue freely or without pain, 
and in some cases attempts to depress it or put it out have caused parox- 
ysms of suffocation. In all the cases it has been difficult or impossible 
to swallow, even a drop of water sometimes causing the patient to cough 
and choke, and in many of them it was necessary to give food through 
an oesophageal tube, in one case for twenty days. The patient finds it 
difficult to speak, and the voice is hoarse and low. 

In the single case in which a fracture of the body of the hyoid bone 
was observed during life the symptoms were severe paroxysms of cough- 

1 On the Dis. and Injs. of the Hyoid Bone, London, 1862, p. 44 ; quoted by Grurlt. 



296 



FRACTURES OF THE HYOID BONE. 



Fig. 154. 



ing, dyspnoea, lividity of the face, and abundant bloody sputa, and were 
relieved by the reduction of the displacement. 

The local and general reaction after the injury has been quite marked, 
and although the bone appears to have united promptly convalescence has 
been delayed by the persistence of the dysphagia and of the change in 
the voice. In one case an abscess formed at the seat of fracture, and 
three months afterwards the necrosed posterior fragment was cast out. 

The possibility of repair by a bony callus is shown by two specimens ; 
one, taken from the body of an adult man without a history and pre- 
sented to the London Pathological Society by Gibb, showing a fracture 
of the right greater horn which had united with overriding to the extent 

of one-quarter of an inch, and displace- 
ment inward ; the other (fig. 154) in 
the pathological collection of the college 
at Brunswick, showing a fracture of the 
right greater horn united with some 
shortening and displacement downward. 
The prognosis, so far as life is en- 
dangered by the injury to the bone, is 
favorable, but the associated injuries 
in the recorded cases have often been 
such as to cause death. Among these 
associated injuries fracture of the car- 
tilages of the larynx is prominent. 

The treatment requires the reduction 
of displacement, if possible ; and this 
may sometimes be facilitated by the introduction of the finger into the 
pharynx. It is unlikely that a bandage would be of any service in op- 
posing a tendency to the recurrence of displacement. The dysphagia 
may render nourishment through an oesophageal tube necessary, and the 
inflammation of the soft parts may require active local treatment. 




United fracture of the hyoid bone. (Gurlt.) 



CARTILAGES OF LAKYXX AXD TRACHEA. 297 



CHAPTER XVI. 

FRACTURES OF THE CARTILAGES OF THE LARYNX AND TRACHEA. 

This injury, although actually rare, is more frequent and much more 
dangerous than fracture of the hyoid bone and has received more atten- 
tion from writers. Gurlt's collection, published in 186-1, contained 47 
cases, Dr. Hunt 1 collected and analyzed 27 cases but did not give the 
details, and Henoque 2 collected 52 cases, to which Mr. Durham 3 added 
10, making 62 in all, or including 4 of Gurlt's in which the trachea 
alone was injured Q6. 

The following table shows the relative frequency with which the differ- 
ent parts are affected: — 



Cartilage broken. 


Cases. 


Deaths. 


.Recoveries. 


Thyroid alone .... 


. 24 


18 


6 


Cricoid alone .... 


. 11 


11 




Thyroid and hyoid bone 


. 4 


2 


2 


Thyroid and cricoid 


. 9 


9 




" " " and hyoid bone 


2 


2 




" "' " and trachea . 


.' 2 


2 




Cricoid and trachea 


2 


2 




" " " and hyoid bone 


.' 1 


1 




"Larynx" 


. 7 


3 


4 


Trachea alone .... 


. 4 


3 


1 



66 53 13 

The causes are blows, falls, hanging, and the grasp of the hand in a 
fight, or in an attempt to strangle. The injury is seen more frequently 
in males than in females, and in middle life than at any other period, 
but youth and old age are not exempt. The mechanism of the fracture of 
the thyroid or cricoid is usually either lateral compression on both sides 
or pressure backwards against the vertebral column ; the first causes 
commonly longitudinal fracture of the thyroid cartilage near its middle, 
together with flattening or depression of its sides, and either a double 
lateral fracture of the cricoid cartilage or a single fracture in the anterior 
median line ; the second causes irregular and multiple lines of fracture. 
The mucous membrane of the larynx is frequently torn, and extravasa- 
tions of blood take place under the skin and mucous membrane or among 
the muscles. 

The symptoms of fracture of the larynx are frothy bloody expectora- 
tion with convulsive coughing and usually much dyspnoea and its atten- 
dant symptoms. The voice is affected or lost, and swallowing often 

1 Am. Journal Med. Sciences, April, 1866, p. 378. 

2 Gazette Hebdomadaire, Sept. 25th and Oct. 2d, 1868. 

3 Holmes's System of Surgery, Am. ed., vol. i. p. 697. 



298 CARTILAGES OF LARYNX AND TRACHEA. 

difficult and painful, although not so much so as after fracture of the 
hyoid bone ; and in all severe cases, when there is laceration of the 
mucous membrane, emphysema appears promptly and spreads steadily 
over the neck, face, trunk, the extremities, and mediastinum, being some- 
times more marked in the intermuscular than in the subcutaneous con- 
nective tissue and sometimes causing pneumothorax without wound of 
the lung. 

The additional objective symptoms are deformity of the region and 
abnormal mobility of parts of the larynx upon each other, but both these 
signs may be unrecognizable on account of the swelling. 

In some cases there have been no marked symptoms beyond a change 
in the voice, although the character of the injury was made clear by 
careful examination, and the difference seems to be due to the absence 
in these cases of any obstruction or narrowing of the air passages by 
displaced cartilages. 

The course in the severe cases is towards prompt death by suffocation, 
either by gradual increase of the dyspnoea or by the sudden intercur- 
rence of oedema of the glottis. Occasionally the dyspnoea does not 
make its appearance until some days after the injury. In the mild cases 
the symptoms gradually subside, and recovery follows. 

It seems probable that repair is by a bony, or at least by a calcified, 
callus. 

The treatment in the milder cases consists of local antiphlogistics and 
quiet ; in the severer ones, of tracheotomy whenever the dyspnoea is 
great or increasing. It is not safe to wait until it has become extreme, 
for its increase at the last is often so rapid and sudden that death takes 
place before relief can be given. It is therefore the part of prudence 
to interfere early and before the interference is made actually necessary 
by the defective breathing. Advantage should be taken of the oppor- 
tunity afforded by the operation to reduce any displacement that may 
exist and that can be overcome by manipulation through the wound. 

The symptoms of fracture of the trachea are similar to those of frac- 
ture of the larynx, except the local ones due to the displacements ; the 
diagnosis is difficult because of the lack of symptoms distinctive of the 
seat and character of the lesion. The prognosis is unfavorable, and the 
treatment usually insufficient to avert the fatal termination or relieve the 
suffering, because in the few recorded cases the seat of injury has been 
beyond reach by operation. The indication for treatment is to insert 
a tube into the trachea past the point of fracture so as to insure free 
breathing. 



FRACTURES OF THE STERNUM. 



299 



CHAPTER XVII 



FRACTURES OF THE STERNUM. 





The sternum, formed originally of several pieces, has an irregular 
and uncertain development, only one feature of which, however, needs 
to be mentioned in this connection. The up- 
per portion, the manubrium, usually unites 
by ossification with the central portion, the 
body, during the early period of adult life, 
but sometimes this union is delayed or actu- 
ally given up, and in the latter case the con- 
nection between the two parts may be a real 
joint with cartilages of incrustation, a capsule, 
and synovia. A traumatic separation of these 
two portions under such conditions, is a dislo- 
cation or diastasis rather than a fracture, but 
as the distinction cannot always be recognized 
with certainty upon the patient, and as the 
symptoms and treatment are the same in 
either case, it seems advantageous to follow 
the general custom and describe all cases as 
fractures. The pathognomonic sign of a dis- 
location or diastasis, according to Malgaisme, 
is the recognizable outline of the articular 
border, usually the upper one of the second 
portion of the bone, which presents three fa- 
cets, a central one for articulation with the 
manubrium, and one at each angle facing 
upward and outward for articulation with the 
second rib (fig. 155). 

The great rarity of the accident is clearly 
shown by statistics, only 22 cases appearing 
in the 22,616 fractures of all sorts treated 
during twenty years at the London Hospital 
(see table page 35), less than one-tenth of 
one per cent. It is unknown in childhood, 
the earliest recorded instances being one at 
the age of 15 years, one at 18 years, and a 
doubtful one at 14 years. As it is usually 
caused by great violence it has frequently 
been found associated with other fractures, 
especially with those of the ribs and vertebrae. 

The fracture may be incomplete, multiple, transverse, oblique, or 



Diastasis of the sternum. 
(Malgaigue.) 

Fior. 156. 




Longitudinal fracture of the 
sternum. 



800 FRACTURES OF THE STERNUM. 

longitudinal. Of the first form there are but two recorded instances ; 
in both the infraction occupied the posterior surface of the bone at or 
near the junction of the lower and middle thirds, was transverse in one 
and oblique in the other, and in each was accompanied by an abundant 
extravasation of blood into the anterior mediastinum. One was caused 
probably by the kick of a horse, the patient being found dead upon the 
floor of a stable, the other by a fall upon the head from a height of 
about ten feet. 

Of compound fractures, except such as were gunshot or stab wounds, 
there is but one example, reported by Duverney in 1751. A quarry- 
man, while at work lying upon his side, was caught under a heavy stone 
about five feet long which compressed his chest laterally with such force 
as to separate the middle portion of the sternum from the upper portion 
and force it through the skin. Death was immediate, by rupture of the 
heart and lungs. 

Of pure longitudinal fracture there is but one certain example, 
although there are two other cases in which there was a longitudinal 
fracture of the manubrium or of the body of the sternum associated in 
one of them with a transverse fracture at the junction of these two parts, 
and a third in which the diagnosis of longitudinal fracture, based upon 
the history of the case and the presence of a supposed callus, was made 
several years after the occurrence of the accident which was supposed 
to have caused the fracture. The first case was that of a man who was 
overthrown and crushed by a falling wall ; in addition to numerous con- 
tusions, the sternum was broken longitudinally throughout its entire 
length, the right half being depressed from 8 to 10 lines below the level 
of the left half. There was profuse bloody expectoration and difficult 
breathing. Reduction was accomplished by drawing the right arm back 
and making forcible pressure upon the middle of the sternal ribs of the 
right side and gentle pressure upon the left side. The patient recov- 
ered in six weeks. 

In the doubtful case the supposed fracture was caused by muscular 
action ; the patient, a lad of 14 years, Avhile quarrelling with comrades, 
retreated into a corner, fixed himself there by pressing with his hands 
upon the walls, and defended himself by kicking. While thus engaged, 
he felt a sudden slight pain in the breast, and found himself unable to con- 
tinue the pressure with his hands. A few years later he studied medi- 
cine, his attention was directed to fractures of the sternum, and, recalling 
this incident of his youth, he suspected a fracture and had himself ex- 
amined, in 1798, by several surgeons, who found what they supposed to 
be a callus occupying the centre of the bone along its entire length. 

Cases of congenital fissure of the sternum have been reported as 
longitudinal fractures. 

Simple transverse fractures form the great majority of fractures of the 
sternum, and occupy most frequently the junction between the manu- 
brium and the body of the bone or its immediate neighborhood, that is, 
the region of the second intercostal space ; next in frequency are frac- 
tures at or near the middle of the bone, corresponding to the third rib 
and the third intercostal space ; they are rare in the manubrium and 



FRACTURES OF THE STERNUM 



301 



below the middle of the bone, and very uncommon as separations of the 
ensiform appendix from the body. 

Fractures of the manubrium occur, according to the few cases in 
which their position has been accurately described, most commonly a 
short distance, two or three lines, above the lower border of this portion 
of the bone ; the periosteum sometimes remains untorn upon either the 
anterior or the posterior surface ; in some cases there has been no dis- 
placement, in others either the upper or the lower fragment has been 
displaced forward, and in one case there was angular displacement, the 
apex of the angle being directed inward. In several of the cases the 
fracture was produced by muscular action, by straining during childbirth, 
or by the effort to raise a heavy weight with the teeth, the body being 
bent far back. In a large proportion of cases in which the lesion was 
produced by external violence, there was also fracture of the ribs, clavi- 
cle, or vertebrse. 

Partial fractures have been observed in two instances, once in connec- 
tion with fracture of the ribs, a scale of bone corresponding to the arti- 
culation with the first rib being broken off ; a second time in connection 
with dislocation of the sternal end of the clavicle, the portion to which 
the sterno-cleido-mastoid was attached being torn off and drawn upward 
nearly half an inch ; and in a third case in connection with a transverse 
fracture lower down. 

Transverse fracture at or near the junction of the manubrium and 
body of the bone, and diastasis at this point, which is not always to be 
distinguished from fracture, are the commonest forms of injury. In the 
great majority of cases the lower fragment is dis- 
placed so as to lie in front of the upper one, and 
sometimes to override ; it is exceptional for displace- 
ment to be absent or for the upper fragment to lie in 
front of the lower one. 

There is reason to think that the periosteum is 
almost invariably torn upon the anterior surface, 
but that it sometimes remains untorn behind, a fact 
which derives considerable importance from its bear- 
ing upon the escape of blood into the anterior 
mediastinum. One or both of the second pair of 
ribs usually remain attached to the manubrium. 

Out of a total of 105 cases of fracture of the 
sternum collected by Gurlt, 27 are described as 
partial or complete diastasis at the junction of the 
first and second portions, the character of the lesion 
having been determined by post-mortem examination 
in fourteen of them. 

Fractures of the body of the sternum (fig. 157) 
occur most frequently between the second and fourth 
costal cartilages, are usually transverse, but some- 
times oblique laterally or from before backward. 
The displacements are the same as after frac- 
ture at the i unction of the manubrium and sternum, 

-■ . . , " Transverse fracture of 

and there is the same relative frequency of the the body of the sternum. 



Fi-. 151 




302 FRACTURES OF THE STERNUM. 

projection of the lower fragment. Sometimes the fragments move 
quite freely upward and downward upon each other during the acts of 
respiration. 

Comminuted fracture of the body of the sternum has been rarely 
seen except in connection with gunshot and punctured wounds. Of 
triple fractures Gurlt found only two cases, and of double fractures 
only six, all of them associated with fracture of other bones, usually 
the ribs or vertebrae. 

Of fracture or diastasis of the ensiform appendix, Gurlt collected only 
four examples, and the list does not appear to have been increased by 
subsequent writers ; one was a fracture, the other three diastases. The 
fracture was produced in a man sixty years old, by a fall upon the 
sharp edge of a grain measure, and, when last examined, nine months 
after the accident, was still ununited and crepitated on pressure, but 
caused no inconvenience. In the other three cases the prominent 
symptom was persistent vomiting, which in one lasted for two years, 
recurring every five or six days, and then ceased spontaneously ; in 
another it was cured by grasping the process between two fingers, and 
bending it back into place ; and in the third, after it had lasted a month, 
and death by exhaustion seemed imminent, it was instantly relieved by 
the reduction of the displacement, which was accomplished by inserting 
a blunt hook into the abdominal cavity through an incision, and draw- 
ing the process forward. The patients were aged respectively 28, 18, 
and 19 years. 

The effusion of blood, which is observed after all fractures, may attain 
an especial importance after fracture of the sternum, by the pressure 
which it may exert upon the underlying heart. The blood, coming from 
the torn vessels of the bone and periosteum, makes its way forward into 
a region where it can do no harm, if the periosteum on the posterior 
surface remains untorn ; but if this membrane shares in the injury, and 
especially if one of the internal mammary veins or arteries is ruptured, 
the blood makes its way into the anterior mediastinum, and sometimes 
in sufficient amount to cause death promptly. 

Rupture of the pericardium, or of the heart, has been observed in a 
few cases ; as has also probable laceration of the lung, evidenced by the 
appearance of subcutaneous emphysema or pneumothorax. 

Etiology. — Fracture of the sternum may be produced either by mus- 
cular action or by external violence. 

There are four recorded cases in which the bone has been broken by 
straining during labor, and three in which the fracture has occurred 
during an effort to lift a heavy object. An example of the former has 
been quoted in Chapter IV. ; the following is an example of the latter. 

A woman was trying to lift a heavy basket into a wagon, and, while 
standing with her head and shoulders thrown back and the basket rest- 
ing against her belly, felt something crack in her chest with pain. A 
transverse fracture of the manubrium, two lines above its lower border, 
was recognized, with displacement forward of the lower fragment, ab- 
normal mobility, and sharp pain on raising the chin, moving the arms, 
or coughing. 

External violence acts either directly by a blow upon the breast, or 



FRACTURES OF THE STERNUM. 303 

indirectly by forcibly bending the body forward or backward, or possi- 
bly by a combination of the two forms in the fall upon the body of a 
heavy object, or the passage across it of a loaded wagon. It is not 
necessary that the force which acts directly should be very great to 
produce fracture ; it is sufficient for it to act upon a limited area, as in 
a fall upon a stone, or stick, or the edge or corner of a box. 

The violence which produces indirect fracture is, in most cases, a fall 
either upon the shoulders or buttocks, or with the back or breast across 
some fixed object, so that the trunk is bent sharply forward or backward ; 
in the one case the bone is broken by being bent forward, in the other 
by the traction exerted through the muscular attachments at either end. 

The diagnosis is readily made by the objective symptoms, the dis- 
placement, mobility, and crepitation, by the localized area of pain 
excited by pressure, change of position, and the more violent respiratory 
acts. The position of the patient, too, is often characteristic, for the 
shortening; of the sternum bv the overriding of the fragments and the 
pain that is excited by traction upon the fragments lead him to keep a 
semi-recumbent or sitting position with the head and shoulders bent 
forward, and to carefully avoid any movement that tends to straighten 
the trunk. The examination of the bone must be made carefully in 
order, on the one hand, to avoid mistaking some irregularity of develop- 
ment for a traumatic displacement, and, on the other, not to overlook a 
second or third fracture, or even a single one in case there should be no 
displacement. The condition of the adjoining costal cartilages may be 
of much service in doubtful cases, such as diastasis at the junction 
of the first and second portions without displacement; thus, if the second 
costal cartilage on either side is found to project at its point of junction 
with the sternum, and especially if the projection can be reduced by 
pressure, the fact points strongly toward a diastasis. In cases of sup- 
posed injury to the ensiform appendix the frequent irregularities in the 
shape, position, and mobility of that part must be borne in mind. 

The importance of the injury is by no means so great as the mortal- 
ity of the recorded cases would indicate, for this mortality is largely 
due to associated lesions. Gurlt tabulated 98 cases with reference to 
this point, among others, and found that of 54 simple cases 46 recovered 
and 8 died, while of 44 complicated cases, cases, that is, in which there 
was some severe associated injury, only 1 recovered and 43 died. Of 
20 cases in which the fracture was certainly caused by direct violence, 
15 recovered, and 5 died, 3 of the latter being complicated cases. A 
mortality of 8 in 54 cases is high enough to prove the importance, the 
seriousness, of the injury, but so far as can be learned from an examina- 
tion of the records it is not certain that the death was due to the frac- 
ture in all of them ; thus, in the case quoted in Chapter IV., of fracture 
by straining during childbirth, and in another very similar one published 
by Chaussier, death was caused by peritonitis, and although an abscess 
was found at the seat of fracture it seems probable it was the conse- 
quence rather than the cause of the constitutional infection. 

In the following case, 1 on the other hand, the injury itself was appa- 

1 Yirclicvr, Gresanurtelte Adhandlungen, p. 579, quoted by Gurlt. 



304 FRACTURES OF THE STERNUM. 

rently the sole cause of death. A man 25 years old was struck in the 
breast by the pole of a rapidly moving wagon ; he lost consciousness at 
first, and complained after recovery of oppression and great pain in the 
chest. A chill occurred on the fifth day and was followed by several 
others ; death on the eighth day. The autopsy showed a transverse 
fracture at the fourth intercostal space without rupture of the fibrous 
lining of the bone, extensive disorganization of the adjoining soft parts, 
especially the anterior mediastinum, purulent thrombosis of the right 
mammary vein, secondary pleurisy, pericarditis, and perihepatitis, with 
phlebitis at points where venesection has been made. 

In another case reported by Duverney, in 1751, a comminuted frac- 
ture produced by moderate violence caused immediate death by lacera- 
tion of the heart by the fragments. A young man playing skittles 
leaned forward after casting the ball to watch its effect and fell, striking 
his breast upon a stone and dying instantly. The body of the sternum 
was broken, the fragments pressed inward, the pericardium opened, and 
the right auricle torn in three or four places. 

The course in the less severe cases is an uneventful one ; in the only 
uncomplicated case which has come under my care, the patient, a man 
of 60 years, who had received his injury by the fall of a frame building, 
complained only of pain on pressure and on drawing a long breath, was 
able to lie upon his back from the first, and was soon dismissed cured, 
but with a slight projection of the upper end of the lower fragment. If 
pain and oppression are more marked at first they soon diminish and 
disappear, as do also the expectoration of blood, dyspnoea, and orthop- 
noea. In exceptional cases the local reaction may be great and may 
lead even to the formation of an abscess about the fracture. The pus 
may make its way to the surface between the fragments or on the sides, 
and if pulsation is communicated to it by the underlying vessels the 
surgeon may mistake it for a traumatic aneurism. If it collects upon the 
posterior surface and is discharged imperfectly through a small opening, 
the fistule may persist indefinitely, or the unnatural conditions may lead 
to extensive caries of the bone. Both conditions require treatment by 
active operative interference. 

Usually repair takes place in from four to eight weeks, and by a bony 
callus. The persistence of a certain degree of displacement is not un- 
common, and in some cases the deformity has been extreme. One is 
reported in which the bone had been driven in so far by the kick of a 
horse that it was almost in contact with the spinal column and left a 
depression in front in which the head of a six-year-old child could rest. 
The displacement had persisted for ten years, but the patient was per- 
fectly well and there were no notable disturbances in respiration or cir- 
culation. 

Failure of bony union has been observed in a few cases, but does not 
appear to have caused any disability beyond a temporary difficulty in 
abduction and adduction of the arms. 

Gunshot fractures may be penetrating or non-penetrating. A number 
of illustrative cases of each kind are given in the Surgical History of the 
War of the Rebellion. The latter do not differ materially from com- 



FRACTURES OF THE STERNUM. SQ& 

pound fractures due to any other cause, but in the former the prognosis 
is rendered very grave by the associated lesions. 

Treatment. — The first indication is to reduce such displacement as 
may exist. This is not always possible ; the most intelligently directed" 
and persistently conducted efforts have sometimes failed. The usual 
method is direct pressure upon the projecting fragment, aided, espe- 
cially when there is overriding, by traction upon the two pieces. The 
traction must be made, in part at least, through the muscles attached 
to the ends of the bone, and is accomplished sometimes by resting the 
back upon some rather firm object, as a cushion or box, and bending the 
head and shoulders forcibly backward. At the same time the patient 
may be directed to take a full inspiration, and the surgeon presses 
downward against the upper edge of the lower fragment if that one, as 
is usual, projects, or he draws this fragment downward by taking hold 
of the projecting ribs that are attached to it. Various modifications of 
the plan have been employed but all have the same fundamental idea, 
that of traction in opposite directions upon the fragments by forcible 
bending of the body backward. 

A number of operative methods have been proposed for use in those 
cases in which the displacement cannot be reduced by manipulation, 
such as to raise the depressed fragment by a sort of gimlet screwed into 
it, or by an elevator or blunt hook passed under it through an incision, 
or to cut away the projecting portion with the knife or trephine, or to 
press it back with a rod carried directly down to it through an incision. 
Most of these remain as suggestions that have not been put to the test. 
One case has been already mentioned in which the ensiform appendix 
was drawn forward successfully by means of a blunt hook passed into 
the peritoneal cavity ; in another, of fracture at the upper part of the 
sternum with depression of the lower fragment, an incision was made 
with the intention of introducing a hook, but the pleural cavity was 
opened and the surgeon felt it necessary to close the w T ound immediately. 
In another the upper fragment was raised to the proper level by screw- 
ing a sort of gimlet into it and drawing it forward, but it afterwards sank 
partly back again, and a second attempt to raise it was defeated by the 
tearing out of the screw. In a compound fracture caused by a blow with 
a bayonet the depressed fragments were raised with a spatula and one 
of them was entirely removed. The patient recovered after two narrow 
escapes from death by hemorrhage. 

Unless the displacement is actually causing dangerous or distressing 
symptoms these methods of removing it by operation are not justifiable, 
because they carry with them risks that should not be lightly run. The 
pleural or abdominal cavity cannot be opened without danger of setting 
up a fatal inflammation, and the conversion of a simple fracture of the 
sternum into a compound one exposes to the chance of suppuration within 
the anterior mediastinum. On the other hand, the displacement usually 
involves no disability and no apparent or noticeable deformity. 

The subsequent treatment consists in immobilization of the chest, and, 

if necessary, in the use of measures to allay local inflammation and to 

prevent coughing. A convenient dressing is a broad flannel bandage 

pinned tightly about the chest after forced expiration, or bands of adhe- 

20 



306 FRACTURES OF THE STERNUM. 

sive plaster extending from side to side across the front of the chest and 
covering the entire length of the sternum. 

The trephine has been occasionally used to seek for and evacuate an 
abscess supposed to have formed behind the bone, but most authorities 
decline to recommend the measure, because of the uncertainty of the 
diagnosis, and advise that the surgeon should wait for the pus to make 
its appearance either between the fragments or on the side. Agnew 1 
did the operation once and with a satisfactory result, but adds that he 
thinks it is better to wait. The justification for delay must be found in 
the difficulty of making the diagnosis, and as the risks attendant upon 
the operation when performed with antiseptic precautions are certainly 
less than those arising from a confined and growing abscess I should not 
hesitate to do an exploratory trephining if the symptoms indicated the 
presence of pus. The proper plan to pursue, in my judgment, would 
be to remove the disk of bone without division of the periosteum on the 
posterior surface, and then to seek for pus by puncturing in different 
directions with an aspirating needle. 

1 Surgeiy, vol. i. p. 860. 



FRACTURES OF THE RIBS AXD THEIR CARTILAGES. 307 



CHAPTER XVIII. 

FRACTURES OF THE RIBS AXD THEIR CARTILAGES. 

These are among the commonest of all fractures, constituting accord- 
ing to different statisticians from ten to eighteen per cent. Thus, ac- 
cording to Malgaigne, of 2358 fractures at the Hotel Dieu 263 were of 
the ribs ; of 2275 at Guy's Hospital 1 222 were of the ribs ; and of 
51,938 at the London Hospital, 2 including " out-patients," 8261 were of 
the ribs, or about 16 per cent. According to Malgaigne fractures of the 
ribs are almost unknown in infancy and childhood, his statistics contain- 
ing only three cases below the age of twenty years. Coulon 3 says that 
of 140 fractures in children observed by him at the Hopital St. Eugenie 
during one year the ribs were broken only once, and that time by the 
passage of a heavily laden wagon across the chest : several ribs were 
broken, the fractures were incomplete and were recognized only at the 
autopsy. He refers also to a confirmatory statement by Marjolin to the 
effect that he had not seen more than two or three fractures of the ribs 
in 800 or 900 cases of fracture observed in children. I have myself 
observed one case in a child 9 years of age which was not recognized 
until after an abscess had formed and exposed the necrosed fragments ; 
and taking that fact and Coulon's autopsy into consideration I am in- 
clined to believe that fractures of the ribs in children may be more com- 
mon than is supposed, but are overlooked because incomplete. They 
are much more common in men than in women. 

Pathology. — Fractures of the ribs may be partial or complete, simple 
or compound, single or multiple. Partial fractures may be constituted 
either by a fissure involving only one of the borders of the rib and, 
perhaps, separating entirely a longer or shorter fragment of that border, 
or by an infraction. The former is uncommon ; it was observed post- 
mortem in connection with complete fracture of other ribs by Lisfranc 
in a case quoted by Malgaigne, and was also produced experimentally 
by the latter. The fracture in Lisfranc's case is described as a longi- 
tudinal one running for one and a half or two inches along the lower 
border of the third rib ; that in Malgaigne's circumscribed a fragment 
of the lower border of the fifth rib. 

Infractions are similar to those seen in the long bones, that is, there 
is complete fracture on only one side of the rib ; the periosteum is usually 
untorn. They constitute, as a rule, only a slight injury, and are there- 
fore seldom seen post-mortem, except when associated with other frac- 
tures of the ribs, or with other injuries. A remarkable case of death 

1 Holmes's System of Surgery, Am. ed., vol. i. p. 747. 

2 See Table on p. 35. 

3 Traite des Fractures chez les Enfants, 1861, p. 87. 



308 FRACTURES OF THE RIBS AND THEIR CARTILAGES. 

by hemorrhage after partial fracture of the eighth rib is quoted by Gurlt 
from the London Medical Times and Gazette, 1860, vol. ii. p. 607. 
The fracture was caused in a man, thirty years old, by a blow with a 
light cane, which left no mark upon the surface. Symptoms of collapse 
soon appeared, and death in seventeen hours. Five pints of blood were 
found in the right pleural cavity, and appeared to have come from a 
small rent in the pleura corresponding to a fracture of the inner surface 
of the eighth rib, about two inches from its anterior end. A small 
branch was found to leave the intercostal artery close to the rent and to 
pass toward it. 

Complete fractures may be transverse, oblique, irregular, or multiple, 
and may be limited to a single rib, or may involve all the true ones on 
one side, and in some cases even many on both sides. The central ribs 
are the ones most frequently broken, while the first and the floating ribs 
almost always escape. The fracture may occupy any part of the rib ; 
Malgaigne thinks it is more common in the anterior portion than else- 
where, and Hamilton says his own observation confirms this opinion. 
Agnew, on the contrary, says it does not accord with his experience of 
cases treated or specimens examined, most of which showed fracture in 
the posterior half. Malgaigne says he never knew a case of comminution 
except in gunshot fractures, and was never able to produce it experi- 
mentally. 

The periosteum may remain untorn, and the fragments preserve their 
relations to each other, or they may form a re-entrant or a salient angle, 
or override each other by their sides or edges. If several ribs are 
broken completely or partially at the same time and forced inward, the 
depression may remain both broad and deep. Overriding of the fragments 
is impossible unless several ribs are broken at the same time, for the 
muscular and fibrous attachments of the adjoining ones hold the frag- 
ments in place, and the ribs above and below act as splints to prevent 
shortening. When several ribs are broken at the same time the side 
sinks in, and thus shortening and overriding are made possible. In at 
least five cases of double or multiple fracture of one or several ribs the 
intermediate piece or pieces have been so loosened that they moved in 
and out with every inspiration. Malgaigne quotes one of these cases as 
a very exceptional fact ; Gurlt gives the details of five additional ones, 
two of which I reproduce briefly. 

Midcleldorpf saw a woman, sixty-three years old, with an extensive 
multiple fracture of the ribs on the right side, caused by a fall upon the 
edge of a tub; there was extensive emphysema of the right half of the 
body, and hemothorax. At each inspiration the side of the thorax w r as 
drawn in, and at each expiration it was forced out again. Recovery in 
fifty-four days. 

Wutzer and C. 0. Weber saw a man, fifty-six years old, over the 
right half of whose chest a heavy cart had passed from below upward, 
breaking all the ribs on that side except the first and the last, most of the 
fractures being double, and the intermediate fragment corresponding in 
length to the breadth of the wheel. The fragments of the fifth, sixth, 
seventh, and eighth ribs were entirely loose, and moved in and out with 



FRACTURES OF THE RIBS AND THEIR CARTILAGES. 809 

a distinctly audible crepitation each time the patient breathed. The 
patient died on the third day. 

In compound fractures the wound is rarely, if ever, caused by the 
projection of the broken end of the rib, but always by the object which 
produced the fracture. 

The complications include injuries to the muscles, which are rarely 
important, to the intercostal arteries, and to the thoracic and abdominal 
viscera. The intercostal arteries appear to be very rarely injured ; one 
instance has been mentioned already in which hemorrhage from a small 
branch of the artery followed incomplete fracture and caused death. 
Gurlt gives three additional ones, two of which terminated fatally ; in 
the remaining one an aneurism formed which was cured in about six 
weeks by pressure, rest, and restricted diet. Laurent 1 quotes another 
of a man twenty-nine years old, who was standing with his breast rest- 
ing against the edge of a bridge, when a friend sprang unexpectedly 
upon his back. It caused extreme pain in the breast, and an elastic pul- 
sating tumor formed at the spot. Twelve days afterwards the breast 
was as Jarge as that of a woman twenty years old ; its border was hard, 
its pulsations plainly visible to the eye ; it w r as not diminished by pres- 
sure, and gurgling was heard in it on auscultation. Fracture of the 
fourth rib was recognized. It was treated by repeated bleedings, with 
internal administration of ice, ergot, and digitalis. Two days afterwards 
the patient had a sudden attack of suffocation, with small pulse and 
nausea, and the tumor disappeared, leaving only the hard border ; at the 
point of fracture w r as a gap, into which the index finger could be intro- 
duced, and where pulsation could be felt. The right arm had been 
paralyzed since the preceding day. The patient remained very ill for 
three days and then slowly convalesced. In March, 1868, Panas 2 men- 
tioned, in the course of a discussion in the Sociefe de Chirurgie, still 
another fatal case, which had come under his observation ten years 
before. 

A wound of the pleura and of the lungs is a rather common compli- 
cation, and is generally caused by the sharp end of a fragment, but in 
some cases fatal injury of the lung has been caused by the crushing 
effect of the external violence acting through the, perhaps unbroken, 
ribs ; the thorax is compressed by the force, and the lung is put upon 
the stretch in such a manner that it is actually torn, not perforated by 
the bone. The case quoted from Coulon at the beginning of this chap- 
ter illustrates this point, the fractures were incomplete, but the lung w T as 
torn in two places, one rent being in the upper lobe, the other at the 
bottom of the fissure between the upper and middle lobes. Legros Clark 3 
mentions two similar cases ; in one the sixth, seventh, and eighth ribs 
were broken near their angles by a blow from the shaft of a wagon, and 
there was a large rent across the lung, but no perforation of it by the 
ribs ; in the other, a child that had been run over, the lower lobe of the 
lung had been torn almost across, and, " although some ribs were broken, 

1 Des anevrysmes compliquant les Fractures. These de Paris, 1874. 

2 Gaz. des Hopitaux, 1868, p. 180. 

3 Diagnosis of Visceral Lesions, pp. 208 and 209. 



310 FRACTURES OF THE RIBS AND THEIR CARTILAGES. 

the pleura was not wounded." The consequences of the wound vary 
with its size and with the relations existing between the lung and the 
thoracic wall. If these latter are normal, that is, if the lung is not adhe- 
rent at the wounded part, air and blood escape more or less freely into 
the pleural cavity, and the lung collapses ; if, on the other hand, the lung 
is adherent, the escaping air makes its way into the meshes of the con- 
nective tissue, and may spread through the mediastinum, under the peri- 
cardium and pleura, and into the interlobular tissue of the lung itself and 
the subcutaneous tissue on the surface of the body. Emphysema of the 
surface may be produced "also when the lung is not adherent ; the air 
which has escaped into and filled the pleural cavity is forced by the con- 
traction of the chest during expiration out through the opening at the 
fracture, and its place is supplied at the next inspiration by fresh air 
drawn in through the wound of the lung, and thus a small quantity is 
pumped into the outer cellular tissue at each respiration, and this will 
continue until one or the other opening is closed by a clot or exudation 
or a change in the relations of its walls. The following cases will serve 
as illustrations : — 

1. A man 1 received a violent blow in the side from the pole of a 
wagon ; this was followed by coughing, slightly bloody expectoration, 
symptoms of suffocation, almost imperceptible pulse, and livid face. A 
circumscribed tumor appeared about an inch from the vertebral column, 
and became tense at each cough, with a sound like that of enclosed air. 
Emphysema spread over the breast and back, and was relieved by scari- 
fications through which the air escaped with a hissing sound. The 
paroxysms of coughing became more frequent and violent, the dyspnoea 
increased, and death took place on the third clay. The autopsy showed an 
oblique fracture of the " second and third last ribs" (eighth and ninth ?), 
two finger-breadths from their articulation with the spine ; there was an 
opening as large as the end of the finger in the intercostal muscles and 
pleura, and a wound in the lung corresponding exactly to one of the 
broken ribs. 

2. An old man 2 was thrown down and trodden under foot ; several 
ribs were broken, and there was enormous emphysema of the body and 
neck with great dyspnoea, bloody expectoration, and small pulse. The 
autopsy showed a large quantity of air in the anterior and posterior 
mediastina and throughout the interlobular connective tissue of the lung ; 
three ribs were broken on the right side, and there was a deep laceration 
of the right lung. 

3. A man 3 was crushed between two railway wagons, and sustained 
fracture of five ribs — second to sixth — in front and behind, with extreme 
prolonged collapse and expectoration of blood and mucus. A tumor larger 
than an inflated sheep's-bladder appeared over the seat of the fracture, 
was distended at each respiration, and spread over more than half the 
body. Several punctures were made and a bandage applied ; as the 
latter did not properly restrain the rising end of the second rib a spring 

1 Cheston, Pathological Inquiries and Observations. 

2 Dupuytreii, Lemons Orales, 2d ed., vol. ii. p. 210. (Griirlt.) 

3 Provincial Med. and Surg. Journal, 1851, p. 488. 



FRACTURES OF THE RIBS AND THEIR CARTILAGES. 311 

truss was added, and the fractured ends were thus kept in apposition. 
The patient expectorated a considerable quantity of pus streaked with 
blood, but made a complete recovery in six weeks. 

Wounds of the heart are much rarer, and even more dangerous. G-urlt 
collected six cases, in only four of which the wound of the heart appears 
to have been caused by the broken rib ; in the other two it appears to 
have been caused by the compression of the heart between the anterior 
chest-wall and the vertebral column, for the pericardium was untorn. 
The two following cases, from the Dublin Journal of Medical Sciences, 
1837, vol. ii. p. 174, illustrate the two varieties: — 

1. A brewer's man fell under a heavily laden dray, which passed over 
his chest. He was lifted up, complained of pain and weakness, but was 
able to sit on the side of the dray and drive the horse for nearly an hour, 
when, being in the neighborhood of a hospital, he thought he would get 
himself examined. He walked in and lay on a bed, but, on turning on 
his side, he suddenly expired. At the autopsy " it was found that the 
fifth rib was fractured, and that the extremity of one portion had pene- 
trated the pericardium and right auricle of the heart ; it filled up the 
perforation of the pericardium, but had freed itself from the heart." It 
was thought it had remained in the heart until the arrival at the hos- 
pital, and that the sudden death was caused by a change in its position 
that allowed the blood to escape into the pericardial sac. 

2. A Avoman was crushed between a wall and a heavily laden cart and 
died almost instantly. Several ribs were broken and driven into the 
lungs. " The pericardium was distended with blood, the superior vena 
cava having been torn almost completely across from the right auricle." 

There are also a few cases on record in which a broken rib has perfo- 
rated the diaphragm, and even injured some of the abdominal viscera. 
Morgan presented to the Pathological Society of London the specimens 
obtained at the autopsy of a man who had died in consequence of a fall 
from a height of twenty-five feet. The sixth rib had perforated the 
pleura, the edge of the lung, the diaphragm, the ileum, and the spleen. 

Etiology. — Fractures of the ribs may be caused by muscular action 
or by external violence. Violent coughing has caused fracture several 
times, sneezing once, turning in bed twice, an effort to avoid falling 
while walking once, and the exertion made in straightening a scythe 
blade once. Usually it is one of the lower ribs that is thus broken, but 
it has happened also to the fourth, fifth, and sixth. While some of the 
patients have been old and decrepit and their bones possibly more fragile 
than usual, others have been young and vigorous. Malgaigne 1 claims to 
have observed a sort of senile atrophy in the ribs affecting especially 
their thickness and making them much more liable to break ; he says it 
is found also in connection with certain affections of the thoracic wall or 
viscera, and that he had seen it in a case of pulmonary emphysema and 
in one of cancer of the breast. In the latter case the tumor did not in- 
volve either the muscles or the ribs, yet the thickness of the latter was 
not more than one-third or one-fourth that of the ribs of the opposite 
side. 

1 Loc. cit., vol. i. p. 427. 



312 FRACTURES OF THE RIBS AND THEIR CARTILAGES. 

By far the most common cause of fracture is external violence, by a 
blow, fall, or excessive pressure. The fracture may be direct or indi- 
rect, the former being perhaps more common in advanced life by reason 
of the less elasticity of the bone, but it is not often easy to distinguish 
between these two varieties. In double fractures one is often direct. It 
has been claimed on theoretical grounds that in indirect fractures caused 
by pressure upon or near the sternal ends of the ribs the bone would 
yield near its centre, at its point of greatest curvature ; but this view is 
not supported by clinical or experimental facts. On the contrary, the 
fracture is found much more frequently in either the anterior or the 
posterior third, and indeed the point of greatest frequency seems to be 
very near that at which the force is received, an inch or two on the 
outer side of the sternal end of the bone. 

Gurlt gives in connection with this two cases of fracture of the twelfth 
rib, one direct, the other indirect, and as they are thought to be the 
only instances on record I reproduce them here. 

A girl 23 years old broke the twelfth rib on the left side by falling 
against the edge of a step. The fracture was two or three inches from 
the spine, there was much pain and crepitation. Recovery with notable 
displacement in four weeks. 

Legouest 1 saw a case of indirect fracture of the left twelfth rib in a 
man 48 years old, caused by a fall against the edge of a table. The 
pain at first was severe ; on the following day he was found in bed lying 
upon his right side with his head and shoulders well raised and breath- 
ing carefully and with short inspirations. Every movement caused pain ; 
there was an ecchymosis over the anterior third of the rib at the point 
where the blow was received. By pressing upon the end of the rib dis- 
tinct crepitation could be made out at the junction of the posterior and 
middle thirds. 

Symptoms. — The symptoms of fracture of the rib in the less severe 
cases are likely to be obscure. There is often acute pain, catching 
respiration, and cough clue, according to Legros Clark, probably to pres- 
sure upon, or injury to, the intercostal nerve, especially if the fracture is 
in the posterior portion of the rib. Pain is provoked by pressure, in- 
spiration, coughing, sneezing, and certain movements of the body, but 
this may also be the result of a simple contusion without fracture. If, 
however, it can be determined that the pain is felt at a point more or 
less distant from that upon which the blow fell, the fact points strongly 
toward indirect fracture. The same may be said of ecchymosis ; it may 
be due to contusion, but if found at a distance is a sign of fracture. 
Abnormal mobility is sometimes present, but the elasticity and mobility 
of the ribs make its recognition uncertain. It may sometimes be made 
out by placing a finger on each side of the suspected fracture, and press- 
ing alternately with one and the other. The same manipulation may pro- 
duce crepitation, but usually this is more readily recognized by placing 
the hand flat upon the chest, and pressing slightly at different points, or 
asking the patient to cough or draw a long breath. It may also be 
heard sometimes on auscultation of the chest, in the usual manner, and 

1 Gazette des Hopitaux, 1859, p. 65. 



FRACTURES OF THE RIBS AND THEIR CARTILAGES. 313 

may be accompanied after a day or two by a pleuritic friction sound, 
the result of a pleurisy excited by the traumatism, and usually limited 
in area to its immediate neighborhood. The difficulty of detecting 
either crepitation or abnormal mobility is even greater at those points, 
where the ribs are covered by a thick muscular layer, or when there is in- 
flammatory swelling, extravasation of blood, or emphysema. It is not 
uncommon for the patient himself to recognize the crepitation. Malgaigne 
saw a case in which, after fracture of the ninth rib, crepitation could be 
heard by those standing near the patient, whenever he made certain 
movements or drew a deep breath ; and he refers to another in which 
the pulsations of the heart produced the same effect. Emphysema is, 
in itself, a very positive sign of injury to the lung and of fracture of a 
rib if there is no penetrating wound to account for it otherwise. Pneu- 
mothorax, or hemorrhage into the pleural cavity from a lacerated lung 
or an intercostal artery may be present in any of the severer cases ; and 
bloody expectoration, which also points toward fracture, may be present 
in slight cases, and is not infrequently absent in grave ones. 

The symptoms of partial fracture or infraction are seldom definite 
enough to permit a positive diagnosis. 

The course of a simple uncomplicated fracture is usually quite un- 
eventful ; the patient remains quiet, sometimes keeping his bed, and 
breathes carefully and superficially to avoid pain ; after three or four 
weeks he finds these precautions unnecessary, and the surgeon finds on 

Fig. 158. 




Fractured rib three months after the injury was received. (Holmes.) 



examination that the local tenderness has disappeared, and that crepita- 
tion and mobility can no longer be detected. Union by a bony callus 
takes place almost invariably, notwithstanding the defective immobiliza- 
tion of the parts, but, as a consequence of the latter, the callus is likely 
to be large, and, when two or more ribs have been broken, to unite the 
adjoining ones by a bridge of new formation (fig. 159). Solidity is 
given at first by an ensheathing callus, and the union between the frac- 
tured surfaces, even when they are in apposition, may remain fibrous for 
several months. Failure of union is rare ; Malgaigne had met with 
only instance and had heard of only one other. The latter was found 
upon a cadaver, and was a case of real pseudarthrosis with capsule and 



314 FRACTURES OF THE RIBS AND THEIR CARTILAGES. 

synovial membrane. Paulet, 1 however, mentions four additional cases, 
and claims that it is by no means so uncommon as Malgaigne supposed. 
Displacement upward or downward of one or more of the fragments 
may lead to its union with the adjoining rib, or to the formation of a lateral 

Fie. 159. 




Fracture of the ribs ; exuberant callus. (Holmes's Syst.) 



joint between them, as in the next following case, and in the specimen 
of the forearm represented in figure 73 ; or, if adjoining ribs are displaced 
in opposite directions, a gap may be left between them which may lead 
to hernia of the lung, as in the following case which is recorded in the 
Gazette Medicate de Paris, 1832, p. 465, and pictured in Cruveilhier's 
Atlas d'Anatomie Patlioloyique. 

The patient died at the age of 62 years : in his youth he had sustained 
a fracture of the ribs by being crushed between the pole of a wagon and 
a wall. Between the third and fourth ribs on the right side near the 
sternum w r as a reducible tumor composed of normal lung and contained in 
a real hernial sac. The first rib was intact, the second and third were 
broken about three inches from their cartilages w T ith displacement inward 
of the anterior fragment, overriding, and a vertical displacement that 
brought the posterior fragments into contact and led to the formation of 
a false joint between them. The fourth rib was bent sharply downward, 
forming the lower limit of a gap that was four inches long, and two and 
a half inches wide at the widest part, and that was bounded above by a 
small strip of bone extending from the fourth costal cartilage along the 
lower border of the third rib, and becoming attached to the latter near 
its middle. 

A somewhat similar case is mentioned by Mr. Bryant 2 as having been 
under his care at Guy's Hospital in 1876. The sternal ends of the 
third and fourth ribs were broken and driven in without wound of the 
integument by a fall upon a wooden paling. " Hernia of the lung took 
place the size of a duck's egg, but an excellent recovery followed the 
reduction of the hernia and the peristent application of pressure." Still 
another case is described in the following section on fracture of the 
costal cartilages (p. 320). 

It occasionally happens, as in the personal case mentioned in the note on 

1 Diet. Encyclopedique, art. Cotes, p. 70. 

2 Practice of Surgery, 3d Amer. ed., p. 575. 



FRACTURES OF THE RIBS AND THEIR CARTILAGES. 315 

page 142, and in a few similar ones, that repair is interfered with by sup- 
puration and by caries or necrosis of the broken rib, and does not become 
complete until after the removal of the diseased bone or the sequestrum. 
The course and symptoms in the severer cases vary with the degree 
and character of the complications which give them their gravity. E 



°.: 



ui- 



physema may be slight and transitory, or it may continue for days and 
spread over a large portion of the surface of the body. If the air 
escapes into the cavity of the chest, or if the fracture is compound with 
a penetrating wound, the resultant dyspnoea and oppression may be 
extreme, and the physical signs of pneumothorax will be found upon 
examination. If, in addition to the escape of air, there is also free 
hemorrhage into the chest from the torn lung or an intercostal artery, 
the physical signs will be correspondingly modified. Extreme dyspnoea, 
due to congestion of the lung following promptly upon the injury, is not 
uncommon, and pneumonia occasionally results and leads to a fatal ter- 
mination in the old and feeble. 

Legros Clark 1 claims that serious functional derangement, without 
organic lesion of the lung, may result from contusion or concussion of 
the chest, that it may be transient or may be followed by inflammation, 
local or general, of the affected lung, and that it is sometimes observed 
in the lung on the side opposite that which has sustained the injury. 
He mentions illustrative cases of which I quote the following : — 

A lad 12 years old was brought to the hospital after a fall from a 
height of forty or fifty feet which had caused no recognizable injury 
except a few bruises on the trunk and a portion of the humerus. The 
shock was moderate. The next day he had a flushed face and hurried 
and oppressed breathing ; but, though the dyspnoea was urgent, there 
was neither lividity nor coldness of the lips or extremities. The heart's 
action was forcible and frequent, but the sounds were normal. Over the 
left side of the chest there was entire absence of resonance on percus- 
sion and of breath-sounds, and indeed of any sound but the heart's beat, 
except, perhaps, the feeblest murmur just below the clavicle. The 
vocal thrill was equally distinct on both sides. On the right side there 
was normal resonance on percussion, and the respiration was puerile. 
There was neither cough nor expectoration. Four leeches were applied 
over the upper part of the affected lung with almost immediate relief. On 
the following day the boy was breathing quietly ; and in less than forty- 
eight hours all the symptoms had disappeared. 

The prognosis depends largely upon the complications. Simple frac- 
tures without important complications do well as a rule ; the exceptions 
are found mainly in the old and feeble whose lives may be endangered 
by congestion of the lungs, pneumonia, or pleurisy. Cases complicated 
by wound of the heart or pericardium are usually promptly fatal. 
Wounds of the lung are serious, but there are many instances of re- 
covery even in cases where the laceration of the lung was probably 
extensive and accompanied a fracture that was in itself severe. 

Mention may be made in this connection of the case of recovery after 
complete transfixion of the chest from side to side by the shaft of a 

1 Diagnosis of Visceral Lesions, p. 213. 



316 FRACTURES OF THE RIBS AND THEIR CARTILAGES. 

chaise which measured five inches in circumference and penetrated for a 
length of twenty-one inches. The patient survived eleven years, and 
his thorax and the shaft are still preserved in the Museum of the Royal 
College of Surgeons, London. 

Treatment. — The indications for treatment are to reduce any displace- 
ment that threatens to produce a complication, or that causes pain, to 
immobilize the chest-wall, and to relieve or prevent pulmonary inflam- 
mation or congestion. 

Outward angular displacement may be corrected by pressure upon the 
projecting angle, and inward angular displacement may sometimes be 
corrected when the broken surfaces are still in contact, and the fracture 
is situated near the middle of the rib by pressing the sternum backward 
and thus springing the bone out. If the fragments have overridden this 
manoeuvre is worse than useless, for it can only increase the displace- 
ment. Malgaigne says the method was proposed by Lionet for use in 
those cases in which the pain is severe although the displacement is slight. 
Malgaigne himself used it successfully to relieve pain, and found by ex- 
periment upon the cadaver that he could thus partially reduce incom- 
plete fractures, but when he used much force the fracture was converted 
into a complete one. Relief may also be obtained by making the patient 
strain or draw full deep breaths. Ravaton relieved the pain and cor- 
rected the displacement in one case by suspending the patient upon two 
rods passed under his axillae. 

When the displacement was greater and one of the fragments was 
pressed inward Malgaigne ingeniously made use of the other to elevate 
it, pressing it in until the ends met and became locked together by the 
irregularities of their broken surfaces so that the elasticity of the second 
should serve to raise the first. He did this successfully in four cases 
and found that the pain was relieved by even a partial reduction, pro- 
bably because that was sufficient to disengage some point of bone that 
had been driven into the flesh. He found it advantageous to have the 
patient strain while the effort was making. 

For this elevation or removal of a depressed fragment by operation a 
number of methods have been proposed, but very few instances are 
known of the use of any of them. Malgaigne referring to only three 
cases, and Gurlt to only one additional. Malgaigne's cases are those of 
Soranus and Rossi. Of the former he says that a wound of the pleura 
by the bone being suspected, he exposed the rib by an incision, passed a 
strip of metal under it to protect the pleura, and excised and removed 
the splinters. Rossi says he once removed a fragment of a rib, and on 
another occasion raised the posterior extremity (portion ?) of the ninth 
rib by means of a lever introduced through an incision made below it. 
The account of Gurlt's case is equally scanty, a young surgeon is said 
to have resected, in opposition to Stromeyer's express commands, a por- 
tion of the bone in a case of non-penetrating fracture of the seventh and 
eleventh (seventh to eleventh ?) ribs with an unfortunate result. 

Malgaigne says that he never found it necessary to interfere in this 
manner, and that if the occasion arose he should prefer to use a hook 
like a tenaculum, passing it carefully behind the upper edge of the rib 




FRACTURES OF THE RIBS AND THEIR CARTILAGES. 317 

and along its inner surface, and then raising the bone with it. Agnew 
says this is easily done upon the cadaver. 

Immobilization of the chest is effected by surrounding it with a broad, 
snugly drawn bandage of muslin, flannel, or adhesive plaster. Some 
surgeons prefer to use strips of adhesive plaster two or three inches in 
breadth and only long enough to half encircle the chest, which they 
apply to the injured side letting each strip overlap one-third or one-fourth 
the breadth of the preceding one (fig. 160). 
Plaster of Paris has been used in a few instances, Fig. 1( 50. 

as have also sheets of felt or gutta percha moulded 
to the part and fastened on by straps of adhesive 
plaster. 

As the object of the bandage, whatever the 
material employed, is to immobilize the chest by 
suppressing thoracic respiration and making the 
diaphragm do the work it is essential that the 
abdomen should not be compressed, and therefore 
the bandage should be placed as high as pos- 
sible, and, if necessary, prevented from slipping 

7 , , , * 1 \ ill Adhesive plaster strips ap- 

downward by bands passing over the shoulders, piled for fracture of the ribs. 
The guide to the amount of pressure exerted by 

it is the comfort or discomfort of the patient. If the pain is increased 
or the breathing interfered w T ith, the bandage must be loosened or re- 
moved. As a matter of fact, the patient will himself immobilize his chest 
very satisfactorily by breathing carefully and superficially and by select- 
ing and keeping a favorable posture if the movements of the qhest are 
painful ; the bandage, therefore, is seldom more than a comparatively 
unimportant aid. Malgaigne preferred a bandage three or four inches 
wide and long enough to pass once and a half around the chest, and he 
did not place it lower than the ensiform appendix, believing it to be suf- 
ficient, whichever ribs might be broken, to restrain the movements of the 
middle ones. When a circular bandage cannot be borne he recommends 
that a long narrow strip of plaster should be carried from the anterior 
end of the seventh rib on the right side, for example, across the front of 
the chest, under the left arm and across the back to and over the right 
shoulder, thence again across the chest in front, and around the left side 
and back to end at the crest of the right ilium. This immobilizes the 
left side of the chest very effectually and leaves the right side free. He 
suggests that in addition the arm should be fixed to the side. 

The pressure of a bandage is useful also to prevent the spread of 
emphysema. This complication seldom requires any more active treat- 
ment, although scarifications are not infrequently made or the air drawn 
off through a trocar. If either method is used the instrument must be 
applied at a distance from the fracture, so as not to incur the risk of 
making it a compound one. The more dangerous variety of emphysema, 
that in which the air makes its way into the mediastinum and the inter- 
lobular tissue of the lung, is not amenable to operative treatment. 

In pneumothorax it may be desirable to draw T off the air through an 
aspirating needle or a canula in order to relieve the pressure, and if. 
blood accumulates within the pleural cavity in quantities sufficiently large 



die FRACTURES OF THE RIBS AND THEIR CARTILAGES. 

to endanger life by interference with the action of the heart and either 
or both lungs it may become necessary to remove it by aspiration or in- 
cision, but the indications should be very plain before the surgeon decides 
to interfere in this manner, since the removal of the clotted blood and 
the relief of pressure may only lead to a return of the bleeding. Per- 
sistent internal hemorrhage can be treated only by indirect measures, 
because its source cannot be recognized, and if recognized, probably could 
not be reached. It has been found useful to constrict the thighs circu- 
larly at the groin with rubber tubing or a roller bandage just sufficiently 
to arrest the venous current ; this withdraws a considerable amount of 
blood temporarily from circulation and acts as a venesection. It some- 
times arrests bleeding instantly. 

When life is threatened by pulmonary engorgement with extreme dys- 
pnoea, blood should be taken from the arm immediately and freely, and 
the bleeding should be repeated if the symptoms reappear. The older 
records are full of cases showing the benefit of this practice, and among 
modern surgeons, Mr. Bryant recommends it unhesitatingly and forcibly. 
He says: "Bleed with no sparing hand. . . . When relief has 
been obtained arrest the flow immediately, as syncope can only do 
harm," and he supports the advice by the history of the following 
case. 1 

u In a case of severe injury to the chest, caused by the passage over 
it of the wheels of a heavily laden cart, that came under my care some 
time ago, fracture of five or six ribs and dislocation of the clavicle oc- 
curred, associated with collapse, intense dyspnoea, and haemoptysis ; I 
bled the. patient twice in twelve hours, and each time with immediate 
relief, the case going on to good recovery. In it the severe dyspnoea 
and venous congestion, the rapid and hard pulse that came on as soon as 
the collapse of the accident had passed away and the circulation had 
been restored, too surely pointed to an excessive engorgement of the 
lungs, and so if relief were not afforded, absolute suffocation would 
speedily ensue by the patient's own highly carbonized blood. At such 
a crisis, antimony, however beneficial in simpler cases, could not be 
trusted, as there was no time for it to take effect. Under these circum- 
stances bleeding was performed, and, as the blood flowed, life seemed 
gradually to return ; the laborious breathing became quiet and subdued; 
the deadened and congested eye bright and natural ; the pulse from being 
full and hard, softer and less bounding ; and the boy's feelings, released 
from the impression that death was nigh at hand, became more hopeful 
and resigned ; and, as a spectator, I felt such a hope was valid, and that 
success might crown our efforts. After the lapse of twelve hours, how- 
ever, the symptoms returned, and the repetition of the bleeding was 
followed by a repetition of all its benefits. The antimony then came in 
to complete the cure ; by the double venesection the pulmonary vessels 
had been relieved of their congestion, while the antimony, in acting upon 
the circulation, perfected the cure by preventing a return of the former 
threatening symptoms. The benefits arising from the treatment adopted 
in this case have such a lasting hold on my memory that I cannot too 

1 Practice of Surgery, 3d Am. ed., p. 573. 



FRACTURE OF THE COSTAL CARTILAGES. 319 

strongly recommend the practice thus pursued, and the more so, as I 
have seen it equally successful in other cases." 

Fracture of the Costal Cartilages . 

The first mention made of this lesion appears to have been by Zwinger 
in 1698, and it is not again referred to in medical literature until 1805, 
when Lobstein, at Strasbourg, and in 1806, Magendie, at Paris, each 
described it with cases. Additional observations were made by Del- 
pech, Sir Astley Cooper, and Yelpeau, and in 1841 Malgaigne 1 pub- 
lished a paper upon the subject which, six years afterwards, he repro- 
duced in part, in his book on fractures. Since then but little work has 
been done upon the subject, most writers contenting themselves with re- 
producing in substance Malgaigne's chapter. Gurlt collected more than 
thirty cases for the chapter upon it in his book on fractures, and Paulet, 2 
who appears not to have known of Gurlt's work, gives fourteen cases 
which he obtained by a partial search through French periodical litera- 
ture, only four of which are mentioned by Gurlt. The known instances 
of this lesion unaccompanied by other fractures are few in number, but 
still throw sufficient light upon the more important and practical questions 
that arise in connection with it. 

Fracture occurs much more frequently at or near the junction of the 
cartilage and rib than at any other point, and more frequently in the 
seventh and eighth ribs than in any other. The fracture may be double, 
and may involve several cartilages on one side or on both. Paulet gives 
two instances of "double fracture, both healed and without history, having 
been found in the dissecting room. As one of them is also the only 
known example of incomplete fracture, I reproduce the description. 
The observation is attributed to Duguet, but the reference is not given. 
"The eighth and ninth ribs on the left side are the seat of a double 
solution of continuity, the rupture following two parallel vertical lines. 
The first line on the eighth rib is three centimetres from the costo-chon- 
dral junction, and five centimetres on the ninth. The second is three 
centimetres from the first. Both fractures are complete upon the eighth 
cartilage, but only the outer one on the ninth." 

All the recorded fractures have been complete with the exception of 
this one case ; they have been perpendicular to the long axis of the 
cartilage, or very slightly oblique, and the surface has always been 
smooth, without serrations or splinters. 

It is probable that persons advanced in life are more liable to this 
fracture than the young, because of the calcification or ossification of the 
cartilages, but it has occurred in young men (17 years) and even in a 
child 7 years old. 

Displacement has been absent in a very few cases ; in most it takes 
place in the antero-posterior direction, and, in some, the fragments have 
overridden in the direction of the long axis of the rib. This latter form, 
probably, is possible only in the longer and more curved ribs, or when 

1 Bulletins de Therapeutique, 1841, p. 227. 

2 Diet. Encyclopedique, 1st Series, vol. xxi., art. Cotes, 1878. 



320 FRACTURES OF THE RIBS AND THEIR CARTILAGES. 

several adjoining ones are broken. The separation in either of these 
two directions may amount to as much as an inch, but is rarely so great. 
Either fragment may lie in front of the other, although the costal frag- 
ment projects more frequently than the sternal one ; the displacement, 
however, appears to depend entirely upon the direction of the fracturing 
force and upon the position occupied by the patient, and consequently to 
follow no definite laws. 

No instance of a compound fracture of a costal cartilage is on record, 
and the complications are less frequent and, as a rule, less serious than 
those accompanying fractures of the ribs. In some cases where the 
violence has been extreme and many cartilages have been broken fatal 
injury has been done at the same time to the heart or great vessels, but 
not by the penetration of one of the fragments ; the viscera are crushed 
or torn by the continued action of the force after the wall of the chest 
has yielded under it. In a case reported by MacLeod a bullet struck 
the front of a soldier's cuirass and bent it in, breaking the cartilages of 
the fifth, sixth, and seventh ribs close to the sternum. The man went 
to the rear, walked about for two hours, was then taken with violent 
pain in the region of the heart, and died three days afterwards. The 
left ventricle was found ruptured. 

Hernia of the lung has been observed in three cases, one after frac- 
ture of the third and fourth cartilages and rupture of the intercostal 
muscles by the fall of a heavy weight, the second, a double one, after 
fracture or diastasis due to paroxysms of coughing, and the third, ob- 
served by Legros Clark 1 after a blow received from the shaft of some 
•vehicle. In this one the cartilage of the second rib" was driven in, 
creating a gap through which a tumor as large as the first appeared at 
each inspiration and disappeared at each expiration, leaving a depres- 
sion capable of containing at least two ounces of liquid. Recovery in 
three weeks, the gap persisting but "evidently occupied by some 
plastic deposit." 

In seven cases the fracture has been produced by muscular action, 
either an excessive effort, as to avoid a fall or to throw a heavy object, 
or coughing or sneezing. Thus Broca 2 reported the case of a porter at 
the market who having placed a sack of peas upon his shoulder asked a 
comrade to add another to it. The latter threw the second sack heavily 
upon him, and in the effort to avoid a fall under the weight he fractured 
the cartilages of the sixth, seventh, and eighth ribs on the right side at 
points seven or eight centimetres from the median line. 

Fractures by external violence may be direct or indirect ; in many 
cases it is difficult, sometimes impossible, to recognize the mechanism. 
Gurlt thinks the indirect fractures take place at or near the costo-chon- 
dral junction, the force acting upon the rib itself in such manner as to 
spring its anterior end outwards, while in the direct fractures the force 
is exerted upon a restricted area of the cartilage itself, as in a fall upon 
the edge of a tub or step, the blow of a fist, the kick of a horse. The 
following cases will serve as illustrations. 



1 Loc. cit., p. 206. 

2 Quoted by Paulet, loc. cit., p. 83. 



FRACTURE OF THE COSTAL CARTILAGES. 321 

1. A man 46 years old 1 was caught in a mill and crushed between 
the beam and the wall. The ends of all the ribs on both sides projected 
distinctly at their junction with the cartilages, and "his chest was to 
the feeling like a dead body where the thorax had been opened and the 
sternum left loose under the integuments. The outer end of the left 
clavicle was dislocated. The patient was pale, breathless, and covered 
with cold perspiration." Venesection, bandage about the chest, shoul- 
ders retracted by a figure-of-eight bandage. Complete recovery in 
twenty-five days, the ribs still projecting on the right side. 

2. A mason fell sixty feet 2 and died in a few hours. Besides an 
injury to the head and fracture of the ribs there was found a consider- 
able depression of the anterior lower part of the breast on the right side 
due to fracture of the cartilages of the sixth, seventh, and eighth ribs 
with overriding of the fragments for about an inch, which could not be 
corrected even at the autopsy. 

3. A man was thrown from and stepped on by his horse, 3 the hoof 
resting on the upper and anterior portion of the chest. There was some 
dyspnoea, local pain, but no ecchymosis. The fourth cartilage was 
forced backward and downward, the anterior end of the corresponding 
rib projected. At each deep inspiration the cartilage returned to its 
place, but the displacement recurred during expiration. 

The symptoms are local pain and deformity. Crepitation and abnor- 
mal mobility are not often recognizable, but if displacement is present it 
can usually be made out by following the outline of the rib and cartilage 
with the finger and by observing that it can be increased or diminished 
by pressure upon one or the other fragment. It may be easy in some 
cases to say whether the fracture involves the rib or the cartilage, and 
in others whether it is a fracture of the cartilage or a dislocation of its 
sternal end, but the question has no practical importance. In the first 
case examination of the projecting end of the posterior (vertebral) frag- 
ment with an acupuncture needle may show whether it is composed of 
bone or cartilage ; and in the second the outline of the sternum will 
show a small projection if there is a fracture close to it, and a cup-like 
depression if the injury is a dislocation. 

The prognosis, independent of complications, is favorable, and the 
fracture may be expected to unite in three or four weeks. Our know- 
ledge of the mode of repair has been obtained partly by experimenta- 
tion and partly by examination of specimens. When the fragments 
remain end to end and the fractured surfaces are more or less completely 
in contact, a fibrous band unites them, and the union is strengthened by 
an external ring of spongy bone. In a specimen obtained by Basserau 4 
and examined microscopically by Malassez it was found that the cen- 
tral band was partly cartilaginous, and it is asserted that in other speci- 
mens points of ossification have been found. 

When the fragments override, they take, so far at least as the broken 
ends are concerned, little or no part in the repair. Union is accom- 

1 Chas. Bell, Surgical Observation, London, 1817, p. 171. 

2 Magendie. Bibliotbeque Medicale, 1806, p. 82. (Grurlt.) 

3 Bouisson. Quoted by Grurlt. 

4 Paulet, loc. cit., p. 88. 
21 



322 FRACTURES OF THE RIBS AND THEIR CARTILAGES. 

plished by an intermediate band which is at first fibrous and afterwards 
becomes bony (fig. 161) ; or if the fragments are in contact, the new 
bone forms on the sides and the ends (fig. 162), and in both cases it 



Fig. 161. 



Fig. 162. 





Eepair of fracture of a costal cartilage. (Gurlt.) 



Repair of fracture of a costal cartilage. 



envelops the pieces more or less completely like a ring. This ring 
originates apparently in the perichondrium, and its ossification is the 
final result of the formative irritation created by the traumatism, and is 
analogous to the ossification seen so constantly not only in cartilage 
which would normally be transformed into bone, but also in others, such 
as that of the larynx, whose normal evolution does not include that 
change. 

The treatment is similar to that of fracture of the ribs ; reduction of 
displacement if necessary and possible, and immobilization. The former 
must be accomplished, if at all, by pressure, by placing the patient upon 
the opposite side or upon his back, by drawing the shoulders back, or 
by deep inspirations ; the latter by a body bandage, strips of adhesive 
plaster, or, following Malgaigne's example, by a hernial truss so placed 
as to restrain the fragment that tends to project. 



FRACTURES OF THE CLAVICLE 



323 



CHAPTER XIX. 

FRACTURES OF THE CLAVICLE. 

The clavicle is more frequently broken than any other bone in the body, 
the radius perhaps excepted, as a reference to the tables of statistics in 
Chapter I. will indicate, and as the following table compiled from a simi- 
lar source as the others and with more detail will prove. Statistics 
composed only of cases treated in hospital give a frequency that is rela- 
tively much less, because many of the cases are treated as " out-patients." 
Thus the statistics of the Paris hospitals for four years, 1861-64, con- 
tained 7687 fractures, of which those of the leg formed 15 per cent., of 
the ribs 13 per cent., of the radius 9.8 per cent., and of the clavicle 7.9 
per cent. 1 

Fractures of the Bones of the Upper Extremity treated at the Middlesex 
Hospital during a period of Sixteen Years ending Jane 30, 1807. 2 





Age. 


Total. 




to 5. 5 to 15. 


15 to 30. 


30 to 45. 


45 to 60. 


Above 60 






M. 

5 


F. 


M. 


F. 


1 


F. M. 



1 11 


F. 

6 


M. 

7 


F. 


M. 
1 


F. 
1 


M. 
28 


F. 
11 


M. F. 


Scapula . 


3 3 


39 


Clavicle . 


176 


171 


84 


47 


56 


26 


67 


33 


51 


33 


18 


10 


452 


320 


772 


A v ( Upper end . 

| g \ Shaft . 

►3 m ( Lower end . 


1 


4 


7 


2 


5 


. . . 


11 


5 


8 


4 


5 


8 


37 


23 


60 


39 


22 


42 


17 


27 


18 


25 


16 


11 


16 


6 


15 


150 


104 


254 


8 


4 


46 


3 


14 


2 


o 


2 


5 


1 


1 


1 


76 


13 


89 


Olecranon 


1 




t 


2 


23 


3 


14 


5 


8 


4 


4 


5 


57 


19 


76 


Ulna exckid. olecran. 


8 


7 


19 


1 


7 


6 


19 


10 


13 


10 


2 


5 


68 


39 


107 


Radius alone . 


62 


64 


92 


19 


78 


45 75 


57 


45 


123 


21 


87 


373 


395 


768 


Ulna and radius 


20 


17 


71 


11 


15 


7 


8 


9 


9 


12 


4 


8 


127 


64 


191 


Carpal bones . 
Metacarpal bones . 


























1 
141 


"27 


1 


1 


"i 


I'io 


1 


62 


9 


50 


13 


15 


3 


3 




168 


Phalanges 


3 


3 


, 44 


7 


47 


8 32 


13 


24 


5 


4 


1 


144 


36 


180 


Total . 


324 


295 425 
I 


no 


335 


125 315 

! 


169 


196 


211 


60 


u, 


1654 


1051 


2705 



It also shows that in nearly half the cases the patients were not more 
than five years old, that up to this age the frequency is about the same 
in the two sexes, and that afterwards the injury is more common in 
males than in females. Gurlt's Berlin statistics make the frequency 
after the age of ten years nine times as great in males as in females, but 
his statistics include only 113 cases. There are nine or ten recorded 
cases of intra-uterine fracture by external violence. 



1 Diet. Encyelopedique, art. Clavicle, p. 677. 

2 Holmes's System of Surgery, Am. ed., vol. i. p. 



845. 



324 FRACTURES OF THE CLAVICLE. 

Pathology. — It has been found convenient by most modern authors for 
the purposes of study and description to divide the fractures into three 
groups, according as they occupy the inner, middle, or outer thirds of 
the bone. The average length of the clavicle is six inches, and this 
division into thirds of about two inches each corresponds to anatomical 
differences of considerable clinical importance. To the flattened outer 
third are attached the trapezius and deltoid muscles and the strong 
coraco-clavicular ligament binding it to the coracoid process, the inner 
fasciculus of which, known as the coracoid ligament, marks the inner 
limit of this portion, and can sometimes be readily felt upon the living 
body. The dividing line between the inner and middle thirds is not so 
definitely marked anatomically, it corresponds approximately to the 
point where the clavicle crosses the lower or outer edge of the first rib. 
The inner third is attached to the sternum by the sterno-clavicular liga- 
ments ; and to the cartilage of the first rib by the costoclavicular or 
rhomboid ligament. To its upper border is attached the sternocleido- 
mastoid muscle, to its lower the pectoralis major. 

Since the outer third is broadly attached by ligaments to the scapula 
it is apparent that after fracture of the bone in the inner or middle third 
the outer fragment will not be able to change its relations to the scapula 
materially, and that its displacement therefore will be governed by the 
change of position of the latter, by its sinking inward and forward to the 
side of the chest in consequence of the loss of its anterior support. 

The outer portion of the middle third is by far the most common seat 
of fracture, apparently because this is the smallest and most sharply 
curved part of the bone and must therefore yield to indirect violence 
more readily than any other part. Hamilton 1 says that of 157 cases, 
exclusive of gunshot fractures, 127 were in the middle third; and exclud- 
ing the partial fractures, the fracture was nearly always near the outer 
end of this third ;. 4 were in the inner third, 17 in the outer third. He 
adds, further, that he has seen only one case of complete fracture in the 
adult produced clearly by a counter stroke that was not near the outer 
end of the middle third. Of 140 cases treated in the New York Hospi- 
tal, 2 3 were near the sternal end, 4 at the junction of the inner and mid- 
dle thirds, 43 in the middle third, 67 at the junction of the middle and 
outer thirds, and 23 near the acromial end. Of 61 cases observed by 
Hurel, 3 exclusive of double fractures, 44 were of the middle third, 14 of 
the outer third, and only 3 of the inner third; three-fourths of those of 
the middle third were situated at or within half an inch of its outer end. 

The fracture, like others, may be partial or complete, single or mul- 
tiple, simple or compound ; the most frequent form is simple complete 
fracture. Compound fracture is so rare that Gurlt says he could find 
only four examples of it, and Hamilton, who gives the same four cases, 
says he had never met with an example. A case has recently been 
under my care at Bellevue Hospital (1881) ; an Italian laborer was 
struck by a falling stone upon the shoulder and sustained a fracture of 
the right clavicle at a point nearly two inches from the sternal end of 

1 Fractures and Dislocations, 6th ed., p. 195. 

2 Lente, N. Y. Journal of Med., 1851, vol. ii. p. 159. 

2 Les Fractures de la Clavicule, These de Paris, 1867, p. 48. 



FRACTURES OF THE CLAVICLE. 



325 



the bone. The line of fracture was oblique from above downward and 
inward. A large ragged wound extended backward across the clavicle 
and shoulder, in which some of the divided fibres of the trapezius could 
be seen. The outer end of the inner fragment was directed sharply up- 
ward, the outer fragment lying below and a little distance from it. The 
wound healed almost entirely in about six weeks, but when last seen 
there was still a sinus over the end of the inner fragment from which 
pus flowed freely and through which a probe could be passed to the bone. 
Incomplete or partial fracture is, according to Hamilton, who has given 
much attention to this variety, very common. He thinks that 3-1 of the 
157 fractures of the clavicle recorded by him 1 were partial fractures, 
and says that at least eleven of these were immediately and sponta- 
neously restored to their natural axes. The symptoms accepted for this 
diagnosis are the history of a fall upon the shoulder, or at least indirect 
violence, the youth of the patient, a swelling upon the upper surface 
and front or rear border of the middle third of the bone appearing with- 
in two or three days after the accident, possibly a change in the axis of 
the bone, and possibly ability to straighten it with slight crepitus. 

Fig. 163. 




Oblique fracture of the clavicle. 

1. Complete Fractures of the Middle Third may be oblique or trans- 
verse, the former variety being found most commonly in adults, the 
latter in children. The line of an oblique fracture usually runs inward 
and downward or backward, but may take any other direction and may 
be nearly transverse, or extremely oblique (fig. 163), or practically 
longitudinal as in a case observed by Chassaignac and mentioned by 
Polaillon 2 in which the fracture ran from the centre of the acromial end 
to a point just external to the sterno-clavicular articulation, dividing the 
bone into two longitudinal halves. Transverse fractures are thought to 
always present an irregular or toothed surface, a condition opposing 
displacement ; and in consequence of this fact and of the other that this 
variety is moro commonly found in children, it often happens that the 
periosteum is not torn. Multiple and comminuted fractures are rare. 
Hamilton has seen only six cases of the- latter, exclusive of gunshot frac- 
tures, all occupying the middle third. I have seen one such, also of the 
middle third, with much displacement of the fragments and threatening 
of perforation by the sharp end of one of them, which was, however, 
prevented. When the fracture is multiple or double, the intermediate 
fragment is likely to occupy a very irregular position. 



1 Fractures and Dislocations, 6th ed., p. 90. 

2 Diet. Encyclopedique, Art. Clavicle, p. 682. 



326 



FRACTURES OF THE CLAVICLE. 



The displacements which are the most common are produced bj the 
falling forward, downward, and inward of the shoulder, the consequence 
of the loss of the support normally furnished by the clavicle, and depend 
somewhat upon the direction of the line of fracture. The commonest 
form is that in which the sternal fragment is drawn upward by the sterno- 
cleido-mastoid muscle or pushed upward by the other fragment which 
is displaced inward along the under or anterior surface of the other and 
has at the same time changed its direction somewhat by the sinking of 
its acromial end. The shortening may be very notable, nearly one- third 
of the entire length of the bone in a specimen mentioned by Malgaigne. 
Another form is found where the line of fracture is such that the frag- 
ments do not readily leave each other, and the broken ends are displaced 
together upward and backward by the falling in of the shoulder so that 
the bone forms an angle at the seat of fracture. In some exceptional 
cases the outer fragment has lain upon the upper or posterior surface of 
the inner fragment. Malgaigne 1 says this variety was mentioned by 
Hippocrates, and that he himself saw one, but only one, example of it. 
Under these circumstances the sternal fragment is held down instead of 
being pushed up by the other one, and the displacement is mainly in the 
direction of the latter, the inner end of which is turned upward forming 
a projection at the seat of fracture. Figs. 164 and 165 represent ex- 

Fig. 164. 




Fracture of the clavicle. Union with extreme displacement. 
Fie. 165. 




Fracture of the clavicle. 



treme angular displacement after fracture, in one case in the outer third, 
and in the other near the inner limit of the middle third. 

In transverse fractures the broken surfaces seldom leave each other, 
and the only displacements possible are in thickness and direction, the 
lateral and angular. The lateral is the one usually seen, the angle 
being directed, for reasons that have been already stated, upward and 
backward. 

The most common and persistent cause of these displacements is un- 
doubtedly the tendency of the scapula and shoulder to fall forward and 
inward upon the chest, but it is aided largely in the first place by the 



i Loc. cit., p. 468. 



FKACTURES OF THE CLAVICLE. 327 

fracturing force which continues to act after the bone has yielded to it. 
Thus, in a fall upon the shoulder or the outstretched hand, the clavicle 
breaks by the exaggeration of its normal curves, and as the direction of 
the line of fracture is usually downward and inward the outer fragment 
is forced inward on the under side of the other and necessarily turns the 
outer end of the latter upward. In like manner, if the fracture is by 
direct violence acting downward and backward the force, continuing to 
act after the bone has broken, depresses the broken ends in the same 
direction. 

2. Fractures of the Outer Third. — This variety is next in frequency 
to the preceding, and may be produced by direct or indirect violence. 
The direction of the line of fracture is more commonly transverse than 
oblique. The degree of displacement varies greatly in different cases, 
being very notable in some and slight or entirely absent in others. R. 
W. Smith, of Dublin, attributed these differences to the position of the 
fracture, according as it lies within the area of the attachment of the 
coraco-clavicular ligament, or on the outer side of it, and he maintained 
that displacement was slight or absent in the former case, because the 
fragments were retained in contact by the untorn ligament that was 
attached to both, and might be great in the latter, because then the outer 
fragment was uncontrolled by fixed bands. Gordon 1 called in question 
the accuracy of both the explanation and the statements, claiming not 
only that displacement might be very marked when the fracture lay 
within the region of the ligament, but even that the majority of the 
fractures lay within this portion. Gurlt accepts Gordon's views, so far 
at least as to admit that displacement may, or may not be present, and 
supports them by reference to specimens. He further criticizes Smith's 
estimate of the distance to which the attachment of the ligament extends 
outwardly, and gives it a much wider range, one that includes all but 
about the outer inch of this division of the bone. This anatomical fact 

Fig. 166. 



-. J* 




Fracture of clavicle, outer third. Extreme angular displacement. (R. W. Smith.) 

makes one of Smith's own specimens support the statements of his critics 
(fig. 166). When displacement exists it is usually an angular one, the 
apex of the angle being directed backward. In some specimens 2 bony 

1 Dublin Journal Med. Sci., 1859, vol. ii. p. 478. 

2 Smith, in Dublin Journal Med. Sci., 1842, p. 47S, and Fractures in the Vicinity 
of Joints, p. 212. 



328 FRACTURES OF THE CLAVICLE. 

union is shown to have taken place between the clavicle and the scapula, 
presumably by ossification of the coraco-clavicular ligament. It is in 
the form of a prop extending from the under side of the clavicle to the 
base of the coracoid process, and sometimes to the notch of the scapula, 
and usually convex posteriorly. 

When the fracture is external to the trapezoid ligament, that is, when 
it lies within the outer inch of the bone, displacement is the rule, the 
outer fragment turning forward and inward until its axis is at right 
angles with that of the inner fragment (fig. 167) ; sometimes its broken 

Fig. 167. 




Fracture of clavicle, outer third. Union with displacement of outer fragment. (E. W. Smith.) 

surface lies against the anterior border of the inner one, and sometimes 
the outer fragment lies under the inner one. Malgaigne describes a case 
in which, after fracture within half an inch of the articular surface, the 
inner fragment was elevated an inch above the other, and there was 
shortening of nearly half an inch ; the appearance, in short, was that of 
a dislocation upward of the acromial end of the clavicle. An instance 
of extreme deformity after fracture at three-fourths of an inch from the 
acromial end is described and pictured by Smith. " The supra-clavi- 
cular space was diminished in a remarkable manner by the elevation of 
the clavicle which formed a very acute angle with the posterior border 
of the sterno-mastoid muscle. The shoulder was drawn forwards and 
inwards, the distance between the sterno-clavicular articulation and the 
extremity of the acromion being nearly an inch less than upon the op- 
posite side." The outer end of the clavicle is raised high above the 
acromion. The relations of the fragments to each other are shown in 
figure 167. 

3. Fractures of the Inner Third. — The older division, which was into 
fractures of the body and fractures of the outer end, took no special 
notice of this variety which received its first separate description from 
Malgaigne. It is the least common of the three ; Delens 1 who wrote 
the first formal article upon the subject collected 28 cases, to which 
Polaillon, two years later, added 3. The fracture may occupy any point 
in the division, and is more often oblique than transverse. It was 
asserted at first that displacement did not occur if the fracture was 
within the region of the attachment of the costo-clavicular ligament, but 
the contrary has since been proved ; displacement may take place in any 

1 Archives Generales de Med., 1873, vol. i. p. 529. 



FRACTURES OF THE CLAVICLE. 329 

direction, but the commonest one is downward and forward of the inner 
end of the outer fragment, or of the adjoining ends of both fragments 
if they do not separate from each other. Polaillon attributes the princi- 
pal part in the production of this displacement to the action of the pec- 
toral and deltoid muscles upon the outer fragment, and finds support for 
his opinion in the fact that this displacement has always been observed 
after fracture by muscular action ; and as in this variety the fracture is 
usually near the inner articular surface, in a region, that is, where dis- 
placement after fracture by other causes is slight or absent, the argu- 
ment is not without weight although the obliquity of the line of fracture 
in such cases as that represented in figure 168 cannot be entirely foreign 

Fig. 168. 




Fracture of the clavicle, inner third. (Gurlt.) 

to the direction and degree of the displacement. When the fracture is 
transverse the lateral displacement may be slight or entirely absent and 
the periosteum may remain untorn. Longitudinal fracture with commi- 
nution was seen in one case, and Hamilton reports another in which the 
line ran from the articulation upward and outward for one and a half 
inches. The fragments overlapped three fourths of an inch and were 
firmly united. In two cases the end of the outer fragment lay under- 
neath the inner one and both were directed upward and backward. The 
outer end of the inner fragment is acted upon more strongly by the- 
sterno-cleido muscle than by any other, the effect of which is to draw it 
upward, and this effect is increased by the pressure of the outer frag- 
ment when that is forced in front of and below the other, so that when- 
ever the two fractured surfaces leave each other the inner fragment is 
likely to incline upward. 

The opinion has been held in a few cases that the injury was a sepa- 
ration of the epiphysis rather than a fracture, but there appears to be no 
warrant for the view, since the epiphysis is very thin, not more than a 
scale, its point of ossification does not appear until the twentieth year, 
and consolidation is complete within a year or two thereafter. 

3Iultiple Fractures. — But few cases are recorded in which the bone 
has been broken in two or more places ; in some the fracture was by 
direct, in others by indirect, violence. Both fractures have been found 
in the middle third, but more commonly they occupy different thirds. 
When one fracture has been in the acromial, and the other in the inner 
or middle third, the intermediate piece has not shown much displacement, 
and each fracture has followed the usual course of a single one ; but 
when the fractures have been within or close to the limits of the middle 



330 FRACTURES OF THE CLAVICLE. 

third, the displacement has been very notable, and, as in the following 
case briefly reported by Malgaigne, 1 irreducible. 

A little girl suffered a double fracture of the clavicle ; the inter- 
mediate piece, which was about two centimetres long, was turned so as 
to lie vertically between the others, and all the efforts made by Mal- 
gaigne and Guersant failed to correct the position. Union took place, 
but with notable deformity. 

Complications of fracture of the clavicle consist in injuries to the ves- 
sels, nerves, and lungs, and are exceedingly rare, excluding gunshot 
wounds in which the complications are produced by the ball and not by 
the fractured bone. Although the subclavian artery is in intimate rela- 
tions with the clavicle, I find no recorded case of its injury as a com- 
plication of the fracture of this bone. Dupuytren speaks in a lecture of 
having seen two or three cases of aneurism following fracture of the 
clavicle, and Jacquemiei 2 gives a case observed by Blandin, of an aneur- 
ism of the acromial branch of the acromial-thoracic artery following 
fracture by direct violence. Gurlt refers to a case mentioned by Erich- 
sen, as a probable wound of the subclavian artery, but he takes his ac- 
count from a German translation, and a reference to the original work 3 
shows that it was the vein and not the artery that was thought to be 
wounded. 

A few cases are reported of injury to the subclavian or internal jugu- 
lar vein, in some of which the diagnosis was verified by autopsy. In 
the museum of St. George's Hospital 4 is a specimen in which the frac- 
tured end of the bone was driven through the internal jugular vein. 
The patient, a youth aged 23, while standing under a tree during a 
thunder storm was struck by a falling branch and died immediately. 

Of the clinical cases that of Sir Robert Peel is perhaps the best 
known. There was a "comminuted fracture of the left clavicle, below 
which a swelling as large as the hand could cover, and which pulsated 
synchronously with the contractions of the auricles of the heart, formed. 
It was evidently the result of a wound of some large vein, probably the 
subclavian, by the broken end of the bone." There were severe asso- 
ciated injuries, and the patient died. 

A case has been recently reported in which the patient, 5 a man 59 
years old, broke the right clavicle in the middle third by a fall upon the 
shoulder. A large swelling appeared promptly in the supra-clavicular 
region and extended to the parotid ; it did not pulsate, and had a slight 
intermittent murmur isochronous with the pulse . The arm was paralyzed, 
and the radial pulse lost. On the following day the pain was less, and 
the pulse had reappeared. An incision was made, an enormous quan- 
tity of blood escaped, and the patient died at once in consequence of the 
entrance of air into the vein. The fracture was very oblique, from with- 
out inwards and backwards, and the vein was torn completely across by 
the outer fragment. The artery and nerves were not injured. 

1 Loc. cit., p. 466. 

2 Fractures de la Clavicule, These d'Agregation, Paris, 1844. 

3 Eriolisen, Science and Art of Surgery, Am. ecL, 1873, vol. i. p. 348. 

4 British Medical Journal, 1873, vol. ii. p. 82. 

5 Progres Medical, 1882, No. 16. 



FRACTURES OF THE CLAVICLE. 331 

Erichsen 1 reported a case of supposed compression of the subclavian 
vein by one of the small fragments of a comminuted fracture produced 
by direct violence, but admits that the autopsy showed no signs of such 
compression, and that the only reason for suspecting it was the gangrene 
of the arm which appeared on the second day and led to amputation and 
death by pyaemia. He refers in passing to a case of laceration of the 
subclavian vein that had been brought to the University Hospital a few 
years before, but gives no details. 

Finally, Annandale 2 once felt justified in cutting down upon a simple 
comminuted fracture to remove a fragment which he feared was pressing 
upon the subclavian vein, and might cause it to ulcerate. The patient 
died in consequence, it is said, of associated head injuries. 

Gurlt gives four cases of probable injury to the brachial plexus by the 
broken clavicle, but adds that in the absence of direct examination of the 
parts we must remain in doubt as to the exact character of the lesion and 
of the mechanism by which it was produced. Another case is reported 
by Mercier, 3 fracture of the middle third with immediate and persistent 
paralysis of the arm. The accident was caused by the slipping of a 
large cannon, the patient, a sailor, being caught between the muzzle and 
the side of the ship. Mercier thought the inner end of the outer frag- 
ment had torn the nerve trunks. In three of Gurlt's four cases the para- 
lysis and numbness disappeared wholly or in part under treatment. In 
the remaining one it persisted. 

Injury to the lung, as evidenced by emphysema, has been recorded in 
five cases where this symptom seemed to be demonstrative, and in two 
others in which it is much more likely that the emphysema was due to 
the introduction of air through a wound of the soft parts. 

The first five cases are those of Yi^arous, Velpeau, Huguier, Ruble, 
and Mercier. All except the fourth, Ruhle's, are described with all the 
details that are obtainable in the thesis of Mercier above mentioned. 
Ruhle's is mentioned by Bardeleben 4 in a foot-note, as an oral communi- 
cation by Prof. Rlihle to the eifect that he had known after fracture of the 
clavicle and displacement inward of the outer fragment a notable emphy- 
sema to appear immediately without fracture of the rib. Velpeau 5 says 
of his case only that " the outer fragment had been pushed so far by 
the fracturing cause that an enormous emphysema of the entire trunk 
ensued," and that he could recognize no fracture of the ribs. The pa- 
tient appears to have survived. In Huguier's 6 case the clavicle was 
broken by a fall from a height of twenty feet ; the patient was brought 
to the Hopital Beaujon presenting a considerable emphysema of all the 
left side of the chest in front and behind, without fracture of the ribs or 
external wound. There was haemoptysis the next day. 

VigarousV patient had his clavicle broken by a blow from the shaft 
of his wagon while trying to stop his horses which had taken fright at a 

1 British Med. Journ., 1873, vol. i. p. 637. 

2 Brit. Med. Journal, 1873, vol. ii p. 82. 

3 Des Complications des Fractures de la Clavicule, These de Paris, 1881. 

4 Lehrbuch der Chirurgie, 7th ed., 2d vol. p. 405. 

5 Anatomie des Regions. 6 Gaz. des Hopitaux, 1847. 
7 (Euvres de Chirurgie, Montpellier. 



332 FRACTURES OF THE CLAVICLE. 

wolf in the road. His breast, head, and neck swelled immediately, and 
there was so much dyspnoea that he was obliged to lie upon the ground. 
He remained thus for three hours and was then seen by the surgeon, 
who found the chest and neck two and a half times as large as normal, 
and says he had never before seen anything so hideous, so monstrous. 
The patient was bled as often as it was thought he could bear it, band- 
ages were applied, and a great variety of liniments and decoctions 
rubbed over him, but without improvement. Narcotics failed to give 
him rest or to quiet his cough, the pulse became frequent and small, the 
respiration hurried, and the patient was evidently approaching his end. 
The emphysema had spread to the arm and hand, the eyelids were enor- 
mous, and the lips three inches thick and everted. The family then 
assented to the proposition that had been made a few days before, and 
the surgeon made an incision three inches long through the skin over the 
fracture. In a week the emphysema had entirely disappeared, and the 
patient recovered. 

In Mercier's case the patient, a woman 60 years old, was brought to 
the Hopital de la Charity, Paris, service of Despres, on the 30th May, 
1881, with a fracture of the right clavicle at the junction of the outer 
and middle thirds caused a week before by the fall of a shutter. The 
emphysema occupied the upper portion of the body but not the head ; 
the patient suffered somewhat with dyspnoea but made no complaint of 
pain and would not wear any dressing. She said the dyspnoea was 
greatest during the first three days following the accident. The physi- 
cal signs of pneumothorax were not present ; there was no fever, no 
cough, no haemoptysis, no external wound. The emphysema disappeared 
in three weeks, and the patient left the hospital June 22d, the fracture 
not yet united. 

The anatomical demonstration of the immediate agency is lacking in 
all these cases, but the notes in all but one show that the surgeons were 
mindful of the possibility that a fracture of a rib might coexist and 
might have been the cause of the wound in the lung, and that they were 
unable to detect such a complication. In most of them, too, mention is 
made of the depression of the outer fragment, and as the relations of the 
clavicle to the upper portion of the thoracic cavity are such that it is 
not difficult to admit the possibility of a wound of the apex of the lung 
by the broken bone, I think the clinical evidence may be accepted as 
sufficient. 

Etiology. — The clavicle may be broken by muscular action, by direct 
violence, or by indirect violence. Gurlt, writing in 1864, had collected 
twenty cases of fracture by muscular action, and the list has been in- 
creased somewhat subsequently by the experience and researches of 
Delens. In the paper above referred to (Archives Generates, 1873) 
he collected eight cases of fracture of the inner end of the bone, and in 
a subsequent one (Arch. Gen., 1875, i. p. 257) he collected nineteen 
cases of fracture of the body of the bone in this manner, three of which 
were personal. Gurlt asserts that this variety of fracture is found most 
frequently in the middle third of the bone, but his cases are so lacking 
in details that only a few of them can be used to determine this point. 

The efforts by which the fractures w T ere caused were various : lifting 



FRACTURES OF THE CLAVICLE. 333 

a heavy weight ; striking with the hand, a whip or racket ; making a 
vigorous effort that involved the contraction of many muscles, as in 
Legros Clark's case of a lad who, while swinging by the feet from a 
trapeze, tried to raise himself so as to seize the bar with his hands ; the 
clavicle broke in its inner third during the effort. It is probable that 
the clavicular fibres of the deltoid and pectoralis major are the most 
efficient agents in producing this fracture, since their contraction tends 
to draw the inner portion of the clavicle downward and outward toward 
the humerus when the arm is fixed, a direction that corresponds, as has 
been already said, with the displacement found after fracture in the 
inner third. 

Closely allied to these cases are those in which the fracture has been 
produced by a blow or other force acting at the hand ; thus, an old 
woman broke her clavicle by closing the door of a wardrobe forcibly, 
and a lunatic at Bice're broke his by striking violently with a heavy 
stick against some iron bars. 

In a very few of the cases the fracture has been produced by two 
efforts, or a blow and an effort, separated by a longer or shorter interval ; 
the patient feels pain at some point in the clavicle after a fall or a blow 
or an effort, which persists perhaps, but is not severe and does not inter- 
fere with the use of the arm ; and then in a few days, after another 
violence or effort, the bone breaks. If the second violence were suffi- 
cient in itself to account for the fracture, the first one might be regarded 
as a mere coincidence, but it has generally been less than the first. 

Direct fractures are produced by very various causes, and may occur 
at any part of the bone, but most frequently in the middle and outer 
thirds. The commonest form of violence is a blow falling upon the cen- 
tre of the bone in a direction that is backward and downward. 

Indirect fractures, which constitute the great majority, are most fre- 
quently produced by a fall upon the hand, elbow, or shoulder, the arm 
being extended and the muscles rigid. In a few cases the fracture has 
been caused by the sudden depression of the shoulder, by which the 
clavicle was bent over the first rib. Malgaigne 1 reports one : an incom- 
plete fracture at the middle of the bone due to the slipping of a burden 
from the shoulder to the arm ; and Polaillon 2 another : a man who held 
the end of a lever which was to receive part of the weight of a heavy 
stone, the stone slipped suddenly upon the lever and drew the arm 
which held it downward. The man heard a snap and felt pain in the 
shoulder ; the clavicle was broken in its middle third. 

The clavicle has been broken in a number of cases during intra-uterine 
life by external violence, and occasionally by the midwife or obstetrician 
during parturition. 

jSi mid tan eons fracture of both clavicles is, as might be expected, a 
rare accident. Malgaigne collected six cases, one of which came under 
his own observation ; Gurlt added fourteen to this list, and Hamilton two ; 
Hurel's thesis contains two others, and Polaillon says he found seven 
reported in French journals and observed one himself. Of these last 
eight I can identify four as found also in the other lists, leaving a total 

1 Loc. cit., p. 463. 2 Loc. cit., p. 679. 



334 FRACTURES OF THE CLAVICLE. 

of twenty-eight cases, in eight of which, however, most details are lack- 
ing. In Hamilton's two cases the patients were young boys ; one of 
Gurlt's was a five year old girl and another was a woman ; all the rest 
appear to have been men. Three of the fractures in Hamilton's two 
cases were incomplete. In position, symptoms, and mode of production 
these double fractures do not differ materially from single ones. Of the 
twenty cases in which the mode of production is given, it was in eight 
a force acting upon both shoulders in the transverse diameter of the 
body, and in three it was the caving in of an embankment, the mechan- 
ism probably being the same. In two it w T as by direct violence ; in one 
of them a wounded soldier during Napoleon's retreat from Russia was 
set upon by the Cossacks and pounded with the butts of their guns ; in 
the other a groom was kicked by a horse, each hoof breaking a clavicle. 
The others were indirect or combinations of direct and indirect fractures. 
In one case one clavicle was broken by direct violence, the blow threw 
the man to the ground and caused indirect fracture of the other ; in 
another the patient fell and broke one clavicle, and w T hile lying on 
the ground was run over by a wagon which broke the other by direct 
violence. 

In three of the cases collected by Malsraigne, union failed in both 
bones, and he has left a very complete account of the resultant disability 
in one of them which was under his own care. In the others there was 
apparently but little permanent interference with the functions of the 
arms. In recent cases there is sometimes considerable dyspnoea, which 
Hurel thinks is due to the weight of the arms and shoulders upon the 
thorax, aided perhaps by the loss of power of the accessory muscles of 
respiration, those which pass from the neck or thorax to the clavicle and 
scapula. This dyspnoea is relieved by the dorsal decubitus if the shoul- 
ders rest upon a firm support. The condition of Malgaigne's patient on 
examination three years after the accident was as follows ; the shoulders 
appeared to be below, in front, and on the inner side of their normal 
positions, the shoulder-blades stood out posteriorly three or four inches 
from the chest-wall and were inclined forwards and outwards, and the 
upper part of the chest seemed much contracted. The clavicles were 
broken at the centre, and the outer fragments were below T and behind 
the inner ones. The shoulders could be drawn back slightly, but not 
enough to overcome the displacement forward, and they could be 
drawn forward so far that they were separated by an interval of only 
three inches, measuring across the chest. The arms could be raised to 
the horizontal line in front and on the side, but not behind. 

Symptoms and Course. — The rational and physical signs common to 
most fractures are found in those of the clavicle. These are the de- 
formity, mobility, and crepitation, the localized pain, and the diminution 
of function. Besides the deformity due to the displacement of the frag- 
ments, there is also that which is produced by the falling inwards of the 
shoulder and which is most apparent when viewed from behind, and with 
it goes a very noticeable projection of the posterior border and inferior 
angle of the scapula. These signs are of course most marked in cases 
of complete fracture with overriding of the fragments; in fractures of 



FRACTURES OF THE CLAVICLE. 335 

the inner and outer thirds they are usually less marked, or even absent, 
because the average displacement is less. 

In fractures of the middle third there is usually displacement of such 
a character and extent that there is no difficulty in recognizing it and its 
cause ; the fragments can be separately grasped and moved upon each 
other. Crepitation, however, is not always produced by this manoeuvre, 
for the broken surfaces may not be in contact, and in order to get this 
symptom it is necessary to have the shoulder drawn backward and out- 
ward, so as to reduce the displacement. 

The fixed pain is a valuable sign in partial fractures and in fractures 
without displacement, and it may be the only one that is present imme- 
diately after the injury ; the appearance within a week of a firm oval 
mass at the point where pain was felt confirms the diagnosis of fracture. 
The only probable source of error in such a case would be a periostitis 
due to direct violence which might give rise to a similar lump. 

The interference with function seems to be largely the consequence 
of the pain which makes the patient unwilling to move the arm, rather 
than of any mechanical defect produced by the fracture. It was long 
taught that a patient with a broken clavicle could not raise his hand 
to his head, but this is so far from being the fact that Velpeau declared 
he had not met w T ith two cases in twenty years, in which there was this 
disability. The patient can usually move the arm quite freely back- 
wards and forwards, but cannot raise it or adduct it without pain, and if 
asked to put his hand on his head, will usually flex the forearm, incline 
the body, and bend down his head to accomplish it. The fracture and 
displacement are not entirely without influence in this limitation of the 
movements, but they are not wholly responsible for it. Hurel, 1 who 
profited by his internat at the hospital for convalescents at Paris, to ex- 
amine the later condition of patients with this fracture, found the move- 
ment of circumduction of the arm the last to be regained, and that a 
shortening of half an inch or more dela} r ed complete recovery consider- 
ably beyond the time that was sufficient for it when the shortening was 
less or absent. 

The patient's appearance is often quite characteristic ; he sits with his 
body and head inclined towards the injured side and supports the elbow 
or forearm with the other hand, and some surgeons have held that the 
diagnosis could be made by the simple inspection of the posture. The 
only cases in which the diagnosis can well remain in doubt after even a 
brief examination are those of incomplete fracture, and some of fracture 
close to either end of the bone. The latter may be mistaken for dislo- 
cation ; in fact, one was so mistaken — a fracture of the sternal end under 
the care of Be'clard, at La Pitie, the real character of the lesion appear- 
ing at the post mortem. This error may be avoided if the outline of 
the bone can be accurately traced, but in two cases of dislocation of the 
acromial end of the clavicle with slight occasional crepitation, I have 
found it impossible to determine positively the seat of the accompanying 
fracture, which was, probably, a partial one, running into the joint. 

The progress of the fracture is extremely simple and is rarely dis- 

1 Les Fractures de la Clavicule, These de Paris, 1867. 



336 FRACTURES OF THE CLAVICLE. 

turbed by complications or dangers. Union is usually firm by the end 
of the fourth week, sometimes much earlier, and failure of union is rare. 
Displacement and shortening, however, are the rule, only those cases, 
apparently, being exempt in which the line of fracture is transverse and 
there is no displacement at first. The amount of the shortening may 
vary from a fraction of an inch to one and even two inches, and it may 
be produced by angular displacement, or by overriding, or by both, as in 
figure 169. 




Fracture of the clavicle. Union with extreme displacement. 

The complications that may occur in the course of the repair are the 
ordinary inflammatory ones that may arise at the seat of fracture in con- 
sequence of the bruising of the surrounding parts, or of the failure to 
immobilize the fragments, or special ones due to the pressure of the frag- 
ments or callus upon the vessels and nerves. Cases have been already 
given in illustration of these complications when produced at the time 
of the accident ; those of later occurrence are very exceptional, although 
Delens 1 intimates a belief that the diminution of power observed in some 
cases after recovery may be due to compression of the nerves by an ex- 
uberant callus. Besides his own case Delens was able to find only one 
other, Polaillon's. 2 A few cases in Gurlt's chapter upon fractures of the 
clavicle may perhaps be instances of paralysis due to the pressure of 
a large callus, but it is not possible to distinguish positively between 
the primary and the secondary effects. Delens's case is very satisfac- 
tory. The patient was brought to the hospital, January 1st, 188 L, with 
fracture of the left clavicle and two ribs. The arm was placed in a 
Mayor's sling, and union was complete by the end of the month. The 
patient returned on the nineteenth of March, complaining of great loss of 
power in the left arm ; examination showed marked overriding of the 
fragments, the outer lying in front of the inner one, with a hard firm 
callus two inches thick, atrophy of all the muscles of the left arm, and 
passive congestion of the skin of the hand ; the pulsations of the left 
radial artery were much weaker than those of the right. The posterior 
and lower portion of the callus was removed by operation, the pulsations 
of the radial artery and the appearance of the hand at once became 
normal, and the patient gradually recovered the use of the limb. 

In another case Grosselin removed a portion of callus which had 
caused persistent ulceration of the soft parts covering it. A prompt 
cure followed. 

1 De la resection d'un cal de la Clavicule comprimant les vaisseaux et les nerfs 
sous-claviers, in Archives de Medecine, Aug. 1881, p. 170. 

2 Loc. cit., p. 696. 



FRACTURES OF THE CLAVICLE. 337 

Ossification of the coraco-clavicular ligament has been observed in 
several cases after fracture in the outer third. No description is given 
of the modifications, if any, of the functions of the part produced by .this 
ankylosis. 

Failure of union is rare. The fact that in three of the six cases 
of fracture of both clavicles collected by Malgaigne, the bones did not 
unite, led that author to believe that this double fracture predisposed 
strongly to failure of union ; but as no similar failure has been since 
recorded, and as the failure in at least two of these cases appears to 
have been the result of the lack of treatment, the opinion lacks support. 
A few cases of failure of union after fracture have been recorded, and 
it is worthy of note that it does not appear to have resulted in any 
diminution of function ; in one case carefully examined by Hamilton 
where there was ligamentous union and overriding to the extent of half 
an inch the arm on the affected side w r as in every way as strong and as 
fit for use as the other. In the recorded cases of pseudarthrosis the 
fracture has generally been in the middle third, rarely in the inner one. 
In only twa cases has the pseudarthrosis received operative treatment. 
The seton was used in both, and successfully. 

Treatment. — The indications for treatment are to reduce the displace- 
ment and to prevent its recurrence. The means by which they are to 
be met do not differ materially in the different fractures, but in describ- 
ing them I shall have mainly in mind fractures of the middle third. 

As has been already said, the shoulder and outer fragment are usually 
displaced inward, forward, and downward, and the outer end of the 
inner fragment is displaced upward. The force which produces the first 
displacement is the weight of the shoulder. It must be remembered 
that the shoulder han^s out from the chest as a sign hangs out from the 
side of a house ; the scapula and 

clavicle are two lateral supports, Fi g- !7°- 

and the trapezius muscle is a sus- A s 

pensory one. A glance at figure a'-.. ^^v/ 
170 shows how the fracture of the T*^*^^^^ 

clavicle removes one lateral support, \ ^J ^ ^ S^, 

and how the weight of the shoulder, c -11]^^ ^HftjJ* 

being no longer supported upon that 11/ ^\^ 

side, swings forward and inward if \ 

upon the posterior border of the cf /^^^^ 

scapula as a centre, or rather upon ]\ ^L^iP^^ 

the under surface of that bone as ^^r 

it lies in Contact With the rOUnd Mechanism of displacement after fracture of 

, ,-. ., ..., . the clavicle. A, acromion; C, clavicle; S, sea- 

chest wall, until a new equilibrium pula . A , ? position of the acromioil after the frac 
is found. This movement of rota- ture. 
tion carries the posterior portion of 

the scapula away from the back at the same time that it brings the 
anterior portion nearer the front, and as the upper part of the chest is 
dome-like and not simply cylindrical, and as the movement, the change 
of position, takes place therefore in a vertical as well as in a horizontal 
plane, the shoulder drops and the inferior angle of the scapula rises, by 
comparison at least, if not actually. Reduction, therefore, is to be 
22 



338 FRACTURES OF THE CLAVICLE. 

accomplished by carrying the shoulder back to its former position, and 
retention by supplying the support previously given by the clavicle. 
These indications have been clearly understood since the time of the 
earliest writers, but it has been found very difficult to embody them in 
practice, because there is no means of acting in the desired manner upon 
the shoulder that does not involve an amount of discomfort that patients 
will not ordinarily submit to. Moreover, in some cases surgeons have 
lost sight of the fact that the position of the arm is a secondary one, its 
importance being due solely to its use as a means of acting upon the 
outer end of the scapula, and that it is useless to press the elbow upward 
unless the scapula is left free to be raised by that pressure. It is 
entirely useless to bind the elbow to the shoulder on the same side ; such 
dressings do not raise the scapula. 

One of the methods of reduction employed by Hippocrates resembles 
in principle very closely the dressing suggested by Yelpeau and em- 
ployed with much success by him and others. He placed the hand of 
the affected side upon the opposite shoulder and then pressed the elbow 
forcibly upward and outward. As the arm lies thus across the chest 
its long axis is exactly in the direction in which pressure should be 
made to overcome the usual displacement. Another method employed 
by Hippocrates was to place the patient upon his back with a small hard 
cushion between his shoulders, and then to press backward upon the 
acromion or the head of the humerus while the elbow was pushed up by 
an assistant. Paulus iEgineta made extension by drawing the arm 
upward and outward, and counter-extension by the neck or other arm, 
and he also recommended the axillary pad with the elbow brought close 
the side. Guy de Chauliac placed his knee between the patient's shoul- 
ders and drew them backward. These methods are the types of all 
that have since been used or that are now in use. A modification intro- 
duced by Chassaignac deserves mention. Having observed that the 
displacement could be reduced by extreme elevation of the shoulder, he 
proposed the following method : the surgeon places his breast against 
the shoulder of the uninjured side, clasps his hands under the opposite 
elbow and draws it forcibly upward. The principal objection to the 
method is that if the fracture is oblique the reduction cannot be main- 
tained. 

Reduction, in short, is to be sought by carrying the shoulder upward, 
outward, and backward, acting either directly upon it or indirectly 
through the elbow, or using the arm as a lever. Polaillon recommends 
strongly a method based upon the latter principle ; standing behind the 
patient he passes his hand or forearm into the axilla and draws upw T ard 
and backward with it, while with the other hand he presses the 
elbow against the side and thus forces the shoulder outward. 

In some cases it is necessary to have these efforts made by an assist- 
ant in order that the surgeon himself may be at liberty to make such 
movements of coaptation as may be needed to overcome the obstacles 
offered by points or irregularities upon the surface when the line of 
fracture is transverse or nearly so. In transverse fractures with only 
angular displacement upward and forward it is sometimes sufficient to 
make pressure upon the angle. 



FRACTURES OF THE CLAVICLE. 339 

The physical obstacles that need to be overcome in the treatment are 
so great, and the success that has attended the different methods has 
been so moderate that the number of plans that have been proposed and 
employed is very great, and the history of the treatment shows mainly 
a recurrence of periods marked at first by elaboration and multiplication 
of details and precautions and then by the abandonment of them all and 
the substitution of something very simple. The results obtained by 
the simple scarf or sling are as good as those furnished by the most 
elaborate bandaging, and the discomfort to the patient during treatment 
is much less. 

The differences in the methods depend in great part upon the indica- 
tion which each surgeon has had more particularly in mind, upon the 
displacement which he sought to prevent. Thus, in some the special 
object of the dressing is to maintain the shoulder elevated, in others to 
hold it back, and in others again to draw it outward. The type of the 
first class is a band passing under the elbow and forearm and around 
the neck, the forearm lying across the chest. That of the second is a 
posterior transverse splint to the ends of which the shoulders are made 
fast, or an anterior transverse splint pressing the shoulder back. That 
of the third is the axillary pad used as a fulcrum to force the shoulder 
out by pressing the elbow in. 

When the patient is sufficiently desirous to avoid any visible irregu- 
larity in the outline of the clavicle to bear the discomforts of a prolonged 
rest in bed without change of position, and w T hen the displacement can 
be reduced, treatment in the recumbent position holds out the best pros- 
pect of recovery without deformity. The patient should be placed upon 
his back (or rather upon her back, for it is not probable that any one 
but a lady whose social position requires her neck to be left at times 
uncovered will submit to this confinement), upon a firm mattress with 
the head bent forward so as to relax the sterno-cleido-mastoid upon the 
injured side, and the elbow fastened to the side or chest or raised upon 
a cushion so that the weight of the arm may tend somewhat to force the 
shoulder upward and backward, anatomically speaking. It has been 
recommended also that a firm narrow cushion be placed along the spine 
between the shoulder blades, and Robert preferred to have the patient 
lie not entirely flat upon the back, but inclined slightly toward the un- 
injured side. In one case digital pressure was made upon the frag- 
ments throughout the treatment to insure accurate coaptation. Mal- 
gaigne suggested that blunt hooks with a strap fastening them to the 
elbow, or double hooks like those he used in fracture of the patella, 
might perhaps be substituted for the fingers of the assistant. The 
position must be kept practically unchanged for at least two, and proba- 
bly for three, weeks. 

Quite recently L.angenbuck 1 has used the silver suture. The patient 
was a boy ten years old, the fracture at the junction of the outer and 
middle thirds. The fragments were fastened together with silver 
sutures, both ends cut short, and the periosteum united with catgut 

1 Deutsche Med. Wochensclirift, Jan. 28, 1882. 



340 



FRACTURES OF THE CLAVICLE 




<5 

Fracture of the clavicle 
scarf. 



Mayor's 



sutures. Antiseptic dressings and the Desault 
bandage were used. The result is said to 
have been very good. The scar left by the 
operation would probably be considered as 
objectionable a disfigurement as union with 
the average displacement. 

Mayor's Scarf or Sling (fig. 171) is 
made of a square of muslin the diagonal of 
which is long enough to extend easily 
around the body. The forearm is flexed at 
a right angle and laid across the breast ; the 
cloth, folded diagonally, is laid over it and 
tied around the body so that its folded bor- 
der runs horizontally around an inch or two 
above the forearm, in front of which the 
cloth hangs down. The free point of the 
triangle is then brought up between the 
forearm and the body, and the two folds of 
which it is composed are secured, one on 
either side of the neck, by bands attached 
to the scarf behind and brought forward over the shoulder. 

A modification which makes this more secure was used by Grosselin, 
The forearm rests* between the folds of the triangle, the folded diagonal 
of which thus forms the lowest part of the dressing, while its ends are 
tied around the body as before. The folds that form the third point are 
also secured as before, or, if long enough, are tied together about the 
neck. Richet sought to give additional solidity by adding bands of ad- 
hesive plaster, passing them under the elbow 
and across the opposite shoulder. 

This method is suitable for fractures without 
much displacement, especially for those in 
children with untorn periosteum. 

Velpeau's dressing (Fig. 172) is more 
secure. It is made with a long roller band- 
age. The elbow is brought well in front of 
the chest and the hand placed on the opposite 
shoulder, and the limb is drawn snugly up 
towards the neck by successive turns of the 
roller which, beginning at the opposite axilla, 
pass obliquely across the back, over the shoul- 
der, in front of the arm, under the elbow, and 
back to the axilla ; after three or four such 
turns have been placed the bandage is carried 
circularly around the body covering in the arm 
from below upward. The turns should be 
secured by stitching or by soaking in dextrine or plaster. 

Say re's dressing (figs. 173 and 174). A very convenient and 
popular dressing is the one introduced by Prof. Sayre. It is made of 
two strips of adhesive plaster, each about three inches wide and long 
enough to go once and a half around the body; one end of the first strap 




Velpeau's dressing for fracture 
of the clavicle. 



FRACTURES OF THE CLAVICLE. 



341 



is stitched loosely about the arm just below the axilla, and the other 
carried around the chest from behind forward, as shown in figure 173. 
The second strap is then carried from the top of the shoulder on the un- 
injured side across the back, under the elbow, and along the forearm to 
the shoulder again (fig. 171). The elbow should be drawn back while 



Fiff. 173. 



Fig. 174. 





Sayre's adhesive plaster dressing for fracture 
of the clavicle. First piece. 



The same. Second piece. 



the first strap is applied, and well forward while the second is. It is a 
convenience to the patient to have the plaster carried past the ulnar side 
of the hand so as to leave the latter uncovered. The action of the 
dressing is simply to press the shoulder upward and backward, and its 
principal advantage lies in the solidity which the use of the adhesive 
plaster gives ; sometimes a turn of a roller bandage is placed under the 
plaster to prevent irritation or excoriation. 

The axillary pad, designed especially to prevent shortening by forc- 
ing the shoulder outwards, has been in use for many centuries, and 
reached its highest development at the hands of Desault, of whose com- 
plicated dressing it forms the essential part. He made it of a firm, 
wedge-shaped cushion stuffed with hair, long enough to reach from the 
axilla nearly to the elbow, four or five inches wide, and three inches 
thick. It was placed between the arm and the body with its thick 
base in the axilla, and the elbow was then brought down and fastened 
to the side with a roller bandage. Numerous other turns of the band- 
age were carried under the elbow and over the shoulders to force the arm 
upward and backward. Desault' s dressing was cumbersome and liable 
to slip, and the axillary pad has on more than one occasion caused gan- 
grene of the arm by obstruction of the circulation, or paralysis by pres- 
sure upon the nerves. As now used it is smaller and softer, but, I 



342 



FRACTURES OF THE CLAVICLE. 



believe that whenever it is large and firm enough to accomplish its 
object, it is dangerous, and whenever small enough to be free from 
danger it is useless. It still forms part of many dressings, but I do not 
think its use in its more recent form can be justified theoretically, or 
that the results obtained by it are better than others. I shall, there- 
fore, mention only one dressing of which it forms part, a dressing that 
has been highly spoken of in the past and which is still very popular, I 
believe, in Philadelphia. It was introduced into the Pennsylvania Hos- 
pital by Dr. George Fox, in 1828. 

Fox's dressing (figures 175, 176) consists of an axillary pad, a 
stuffed leather ring, and a sling. The ring is passed over the arm of the 



Fig. 175. 



Fig. 176. 




Fox's dressing for fracture of the clavicle. 



Fox's dressing for fracture of the clavicle. 



uninjured side to the shoulder, and the pad and sling are attached to it 
by straps, as shown in the accompanying figures. Dr. Agnew speaks 
highly of its value in the treatment of fractures of the sternal or acromial 
end of the bone. 

Papini's Brace. — An attempt to meet the same indication by means 
of a fixed brace has been made by Papini, and the instrument seems to 
be well adapted to its purpose. It consists of an artificial clavicle of 
wood made fast to the body and shoulder by a jacket and armlet of 
leather. The arm is secured to the side and the elbow held up by a 
roller bandage. It is adjustable, so that the shoulder can be pressed 
back to the desired extent. 

The dressings which are intended mainly to draw the shoulder back- 
ward are modifications of the figure-of-8 bandage and the posterior and 
anterior splints. The simple figure-of-8 carried across the back from one 
shoulder to the other, is, if not actually harmful, certainly inefficient. 
A modification suggested by Recamier amounts almost to a posterior 
splint. He placed a large, hard square cushion (fig. 177) between the 
shoulders behind and carried a bandage from each upper corner over the 
shoulder and under the axilla back to the lower corner. Moore, of 
Rochester, applied the bandage so as to include the elbow as well as the 



FRACTURES OF THE CLAVICLE. 



843 



shoulder of the affected side, seeking to make the fibres of the pectoralis 
major tense by drawing the elbow backward. The bandage in his dress- 
ing (fig. 178) should be about two yards long, its centre is placed under 
the olecranon, the forearm be- 
ing flexed at a right angle, the 
end that is next the body is 
carried up between the arm 
and the side, in front of and 
over the shoulder, across the 
back and under the opposite 
axilla ; the other end is carried 
around the outer side and 
front of the elbow, then be- 
tween it and the side to the 
back, and across the back to 
the opposite shoulder where it 
is made fast to the first end. 
The elbow must be drawn 
backward and pressed upward.' 
Hamilton expresses approval 
of the principle of this dress- 
ing, but finds its use trouble- 
some to the patient. I do not 
think it is worth while in any 
dressing to seek to draw down 
the inner fragment through the 
agency of the pectoralis major. 

Posterior splints are seldom used now. They have been made in the 
form of a cross, against the arms of which the shoulders were drawn 
back, and as iron, wooden, and pasteboard splints crossing the back and 
extending usually beyond the shoulders, so that the traction of the 
bandages by which the shoulders were made fast should be exerted in 
an outward direction as well as backward. . 

Anterior splints, made of gutta percha or metal, and moulded to the 
front of the chest from one shoulder to the other, have been used with 
the same object, and the attempt has been made to use plaster of Paris 
in the same manner, pouring it over the front of the shoulder and chest 
to solidify while the fragments are held in position. 

I am not aware that the plaster-of-Paris jacket has been used for this 
purpose, and I have had no suitable opportunity to make trial of it ex- 
cept in the somewhat similar dislocation of the acromial end of the clavi- 
cle, but I think it would furnish a fixed point that could be made useful 
by fastening the shoulder to it by additional turns of the bandage. 

It is very apparent upon examination of the history of this subject, 
that w T hile many different dressings may give good results in certain 
cases, none can be depended upon to do so in all, and that the dis- 
placement, the shortening, which is the rule, is the result in some cases 
of forces which cannot be effectually controlled, of the obliquity of the 
fracture, and not infrequently of the indocility of the patient, who, find- 
ing himself incommoded by the dressing, shifts it slightly, but often, 




Fracture of the clavicle. Kecamier's dressing. 



344 



FRACTURES OF THE CLAVICLE. 
Fig. 178. Fig. 179. 




Moore's dressing for fractured clavicle. 



Moore's dressing for fractured clavicle. 



until he obtains ease at the sacrifice of the object it was applied to 
secure. 

If the fracture is without displacement, especially the subperiosteal 
fracture of children, or if the displacement shows but little tendency to 
recur after reduction, the simple scarf or sling or Sayre's dressing will 
answer every purpose. 

If, on the other hand, the tendency to displacement is great, the 
choice of a method of treatment will depend largely upon the character 
and wishes of the patient. If he is indifferent to the deformity or intol- 
erant of restraint, it is useless to attempt more than a simple dressing ; 
but if he is willing to submit to the confinement, the fracture may be 
treated by dorsal decubitus and digital pressure with a fair prospect of 
success. 

If the displacement is irreducible, as sometimes happens, and without 
much tendency to increase, a simple dressing is sufficient. 

In simultaneous fracture of the two clavicles, the dorsal position is 
strongly to be recommended. 

It is well to place in the axilla a pad of cotton wrapped in a compress 
to absorb the moisture and keep the opposing surfaces from contact with 
each other ; and for the same reason a compress should be placed be- 
tween the arm and the body, wherever the two would otherwise be in 
contact. 

If an axillary pad is used, particular attention must be paid to the 
condition of the circulation and innervation, and the examination must be 
made twice or three times a day at first. 

The dressing should be worn for from fifteen to twenty days by chil- 
dren, and twenty to thirty days by adults. 



FRACTURES OF THE SCAPULA. 



345 



CHAPTER XX, 



FRACTURES OF THE SCAPULA. 

Fractures of the scapula are comparatively rare, about one percent, 
of all fractures according to the best statistics at our command. They 
are six times as common in men as in women, and in the great majority 
of cases the patients have been between twenty and fifty years of age. 

The size and shape of the bone, and the presence of three irregular 
and prominent apophyses permit a diversity of fractures differing so 
greatly in their mode of production and symptoms that it becomes neces- 
sary to consider them separately. Most writers in the last hundred years 
have made from six to eight groups as follows : 1st, fractures of the body ; 




Transverse fracture of the sternum. Fracture of the clavicle ; union. 

2d, fractures of the inferior angle ; 3d, fractures of the upper angle and 
supra-spinous fossa ; 4th, fractures of the spine ; 5th, fractures of the 
acromion ; 6th, fractures of the coracoid process ; 7th, fractures through 
the surgical neck ; 8th, fractures of the glenoid cavity. Of these 



346 



FRACTURES OF THE SCAPULA 



Fig. 181. 



varieties the 1st, 4th, 5th, and 7th are by far the most common, the 
others are extremely rare. 

1. Fracture of the Body of the Scapula. — Fractures of the body of 
the scapula are single or multiple. The former are confined to the sub- 
spinous fossa, and the direction of the line of fracture is transverse or 
oblique. The fragments may preserve their normal relations to each 
other or there may be displacement, the lower fragment shifting to either 
side of the upper one and overriding for a greater or less distance. This 
overriding is most marked on the axillary side and is due apparently to 
muscular contraction, while the lateral displacement is the result of the 
continued action of the fracturing force. In some cases the fragments 
have united after transverse or oblique fracture in such a position that 
they touch or override at one side and are separated at the other. 

In multiple fractures the lesion is extremely variable, the fracture may 
be " starred," or comminuted, some of the lines may be incomplete, and 

the main one may be longitudinal ; 
the only condition, apparently, under 
which longitudinal fracture is met 
with (fig. 181). Gurlt doubts if a 
simple longitudinal fracture was ever 
known, although he quotes a case from 
the Lancet (1862, vol. ii. p. 116) 
described as such. 

Malgaigne describes a case of sup- 
posed partial fracture, the diagnosis 
being made during life. The central 
portion of the bone was found de- 
pressed after a blow, with a sharp, 
well-defined, bony margin on the 
spinal side, and rising gradually to 
the level of the bone on the other ; 
no crepitation or abnormal mobility. 
Dr. Hamilton describes a partial 
fracture or fissure found in the 
scapula of an Oneida Indian who 
died of injuries received a few months 
previously in a street fight. The fis- 
sure ran from a point on the posterior border three-fourths of an inch 
below the spine transversely across the body of the scapula for 1} inches. 
There w T as no displacement and no union, but there was a ridge of callus 
along each side of the fissure. Gurlt gives a figure of a specimen 
showing what seems to be a marked infraction of the body below and 
parallel to the posterior half of the spine. 

The cause of the fracture has always been direct violence, usually a 
blow or a fall upon some angular object, but in two cases it was caused, 
with other injuries, by the passage of a locomotive, the patient having 
fallen between the rails and been squeezed between the ground and the 
ash-box as it passed over him. 

The objective symptoms which may be met with are irregularity in 
outline, abnormal mobility, crepitation, and ecchymosis. The posterior 




Multiple (longitudinal) fracture of th< 
scapula. 



FRACTURES OF THE SCAPULA. 347 

border of the bone can be brought into prominence by carrying the fore- 
arm across the chest or behind the back, and then if the finger is passed 
along it a transverse or oblique fracture with displacement will be certainly 
recognized. Abnormal mobility and crepitation are not so readily made 
out, the best plan is to pass the fingers if possible under the inferior 
angle and thus ascertain if it moves independently of the rest of the 
bone. To detect crepitation the palm of one hand should be placed over 
the bone and the arm moved freely in different directions. In multiple 
or partial fractures with depression the adjoining edge of bone may be 
felt, as in Malgaigne's case, if the patient is not too fat or muscular. 
The precaution should always be taken to make a comparison with the 
other scapula, and the normal ridges along the borders and at the base 
of the spine should be borne in mind. Ecchymosis unless due to the 
action of- the violence upon the soft parts, seldom appears until after the 
lapse of a few days. Emphysema was spoken of as a symptom by Petit, 
but has been noticed by no subsequent observers; possibly it was due in 
his cases to concomitant fracture of the ribs and wound of the luns;. 

Localized pain on pressure and on movement of the arm is a constant 
symptom, and may make it impossible for the patient to extend his arm 
horizontally and directly forward because it is so much increased by the 
contraction of the muscles concerned in this movement. 

The course in the simpler cases ends in recovery in four or five weeks, 
usually with preservation of function even if union has taken place with 
some unreduced displacement. Multiple fractures are more dangerous 
because of the greater probability of suppuration at or in the neighbor- 
hood of the fracture, and of course if the fracture is a compound one the 
danger is still greater. In a very few instances there has been much 
disability due to failure of union or to union with displacement and ex- 
uberant callus. Gurlt quotes an example of the former in which the 
patient was unable to raise his hand to the back of his neck, and one of 
the latter in which the disability was almost complete and all communi- 
cated movements of the arm and shoulder painful. 

Treatment. — In simple fracture without displacement no other treat- 
ment is needed than immobilization of the arm and shoulder during the 
length of time necessary for consolidation. If displacement exists it 
must be corrected if possible, but no rules have been laid down by which 
this may be accomplished, no special principles even established by at- 
tention to which the attempt is made more likely to succeed. Great 
diversity exists in the recommendations made by different writers, and 
unfortunately each has to admit the possible failure of his method. Mal- 
gaigne, indeed, after an elaborate description of the mechanism of displace- 
ment and of the means by which it should be reduced and prevented, admits 
that he had never been able even to reduce it, and that sometimes the 
manoeuvres and" positions which seemed best calculated to diminish it only 
increased it. The surgeon therefore should seek to recognize the charac- 
ter of the displacement as clearly as possible, and then should try to 
reduce it by placing the arm and shoulder in various positions and 
pressing upon the fragments with his hands in the directions indicated 
by the displacement. When the latter is reduced as far as possible the 
arm and shoulder must be immobilized by bandages that raise the elbow 



348 FRACTURES OF THE SCAPULA. 

and fix it to the side, and broad strips of adhesive plaster should be laid 
across the scapula to aid in its immobilization. Moulded splints of 
pasteboard, gutta percha, and plaster of Paris have been suggested and 
employed, but they do not furnish enough additional security to com- 
pensate for the discomforts they may cause. 

In comminuted fractures the principal indication is to prevent the 
severe inflammatory reaction which is so likely to follow the bruising 
and laceration produced at the same time by the extreme violence that 
has caused the fracture. If the fracture is compound it must be ex- 
plored through the wound and treated in accordance with the principles 
elsewhere laid down, and I believe that it is prudent in such cases to 
remove partly adherent fragments which could be safely left after frac- 
ture of other bones, whenever by such removal a free outlet that would 
otherwise be lacking is supplied to matter that may accumulate on the 
under (costal) surface of the bone. The experience furnished by frac- 
tures of other flat bones, the skull and sternum, shows the probability of 
suppuration on the under side, and in a few cases of fracture of the 
scapula pus has formed in this manner and caused much trouble by 
burrowing down the side. In one case of simple fracture the surgeon 
felt justified in cutting down upon the bone and removing a large num- 
ber of fragments, but the practice has not been approved by any one 
who has quoted the case, at least not to the extent of laying it down as 
a rule for general application. 

Fractures of the Inferior Angle. — These are included by some sur- 
geons, and with good reason, in the group of fractures of the body of 
the scapula, from which they differ merely by the proximity of the line 
of fracture to the lowest part of the bone, but as they present a more 
constant and well-defined displacement which cannot be readily overcome 
or prevented they deserve separate mention. The recorded instances of 
separate fracture are not very numerous. Gensoul reported one pro- 
duced by muscular action ; the patient saved himself from falling to the 
ground while descending a sharp incline, either by catching hold of some 
support or by falling backward upon his outstretched hand, the abstracts 
of the report are not very clear upon this point. A triangular piece 
corresponding to the inferior angle was detached from the scapula and 
displaced forward and upward, and could be moved independently and 
with crepitation. Grensoul attributed the fracture to the sharp contrac- 
tion of the teres major. In other cases the cause has been a fall upon 
the back. 

The symptoms, apparently, are clear and unmistakable ; displacement 
of the fragment forward and upward by the combined action of the serra- 
tus magnus, teres major, and, according to some, of the latissimus dorsi; 
abnormal mobility recognized by grasping the fragment with one hand 
and moving it, or by fixing it with one hand and moving the scapula 
with the other ; and crepitation. 

The displacement is difficult to reduce or mai